用分层风险控制提升医保人群健康管理的公平性与安全性。

Population health management programs for Medicaid populations coordinate longitudinal outreach and services (e.g., benefits navigation, behavioral health, social needs support, and clinical scheduling) and must be safe, fair, and auditable. We present a Hybrid Adaptive Conformal Offline Reinforcement Learning (HACO) framework that separates risk calibration from preference optimization to generate conservative action recommendations at scale. In our setting, each step involves choosing among common coordination actions (e.g., which member to contact, by which modality, and whether to route to a specialized service) while controlling the near-term risk of adverse utilization events (e.g., unplanned emergency department visits or hospitalizations). Using a de-identified operational dataset from Waymark comprising 2.77 million sequential decisions across 168,126 patients, HACO (i) trains a lightweight risk model for adverse events, (ii) derives a conformal threshold to mask unsafe actions at a target risk level, and (iii) learns a preference policy on the resulting safe subset. We evaluate policies with a version-agnostic fitted Q evaluation (FQE) on stratified subsets and audit subgroup performance across age, sex, and race. HACO achieves strong risk discrimination (AUC ~0.81) with a calibrated threshold ( τ ~0.038 at α = 0.10), while maintaining high safe coverage. Subgroup analyses reveal systematic differences in estimated value across demographics, underscoring the importance of fairness auditing. Our results show that conformal risk gating integrates cleanly with offline RL to deliver conservative, auditable decision support for population health management teams.