medical philosophy and general discussion · 2019-01-29 · working in unison with pricing...
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Medical Philosophy and General Discussion
Dave Rengachary, M.D., FALU
September 10, 2018
SVP and Chief Medical Director
US Mortality Markets
2
Discussion Points
Risk Selection1
Valuation of Medical Information2
Multiple Impairments3
RGA’s Medical Underwriting Philosophy4
Risk Selection
4
Approach to Risk
Risk aversion
‘Reasonable’ risk acceptance
Risk naïveté• Ignorance• Deliberate choice
Risk transfer/share
5
Making a Decision
Manual
Medical knowledge
and referral
Pricing
Available tools
6
Approach to Risk
Working in unison with pricing actuaries• Medical philosophy must be mutually understood and accepted both by
underwriters and pricing actuaries• Actual/expected mortality results• What is preferred pricing?• How was the condition priced?
o Which references/sources were used?o e.g., diabetic neuropathy
• How recently was this condition priced?o e.g., white matter changes on MRI, newer treatments for multiple sclerosis
Valuation of Medical Information
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What Is the Value of Medical Data?
Sources of information (medical history)• Applicant (self-disclosed)• MIB• Paramedical exam• Laboratory
o Correlation with other known datao Sensitivity, specificity, prevalence, predictive value
• Rx check• EKG/treadmill• APS• *MVR
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Cost/Benefit of Medical Information
Financial cost
Time cost
Placement cost
Protective value• Anti-selection• Accuracy of risk assessment• Decline ratio
10
How Much Medical Information Is Needed to Make a Decision?
Routine requirements• Screening purposes
Will additional information stratify the degree of impairment risk?
Will the information make any difference in the eventual decision?
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Can a Decision Be Made with Current Information?
Probably, yes!• But … decision may be to PP or decline, rather than offer• Additional information may result in either:
o An improved offero Verification of initial tentative plano Verification of existing knowledge
• Comforting but wastes time and moneyo New, relevant data that can be protective
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Caveats
Hindsight is 20/20
These cases do not have a “right” or a “one size fits all” answer
You are under pressure from both sides
Key = documentation!
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Case 1
52-year-old male, smoker, $250,000
6.2.264; 122/82
PHI – LOV with PCP 7/15 for yearly physical and blood work
APS from PCP received
3/13: tired in the afternoon and wasn’t sleeping through the night; given CPAP for OSA and uses nightly
2/14: fractured elbow
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Case 1
12/14: infection in arm, given IV antibiotics
1995: surgery for leaky valve
Currently on Warfarin, Niaspan, Enalapril and Simvastatin; has taken testosterone replacement daily since 10/14
Current labs: cholesterol 117, PSA 1.72, HOS nicotine 0.83
APS from cardio received
6/12: echo: LA 46mm (<40mm); EF 70-75%; mechanical aortic valve; mild CLVH; moderate LAE; no significant change since 10/10 study
Would you require the PSG to offer here?
(cont.)
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Deciding on the APS
What is the range of risk encompassed by the missing APS?
Unless one of the risk factors in adjustment table pushes to RNA
Can we then just go out at the maximum rating for all OSA? (No!)
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Case 2 39-year-old male, non-smoker, $2,000,000
5.11.203; 120/80
Client transmittal stated assessed at Table B; case shopped due to international guidelines
Insured is from Ireland, has dual citizenship between Ireland and South Africa, and is in the U.S. on an H1-B visa; plans to stay in the U.S. indefinitely; he is an engineer
LOV to PCP 1/15; he wanted to get an EKG just as a general health test; did it out of curiosity to see what his health is like
Diagnosed with anxiety in 2013 while in Ireland; given Venlafaxine and is still taking it
He had an EKG done at a cardiovascular center; no date was specified
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Case 2
Rated low substandard for labs: ALT 1.1x; GGT 3.6x
Hepatitis screen negative
Cholesterol: 293
EKG not supplied; would you require EKG? Cardiac APS?
Received APS from cardio
3/15: OV for evaluation and follow-up of HTN and hyperlipidemia; denied symptoms; EKG-WNL; DOE likely due to deconditioning but used to be able to exercise more; TM recommended
Would you require TM at this point to offer?
(cont.)
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Deciding on the APS
What is the range of risk encompassed by the missing APS?
What is the pre-test probability of disease (and rating) in this individual?
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Case 3 57-year-old male, non-smoker, $300,000 5.7.209; 116/75 Client transmittal assessed case Table B due to DM history Insured admitted to PCP LOV 4/15 for a DOT physical Chest pain 3 years ago; had a “heart dye test” and everything was fine HTN diagnosed 4 years ago; on Bystolic and Ramipril Type 2 DM diagnosed 3-4 years ago; on Metformin; last A1c was 7.0 On Atorvastatin and Zetia for cholesterol Had a routine colonoscopy 6/14; everything was WNL and he was told to come
back in 10 years Labs (non-fasting): glucose 196; A1c 8.1; cholesterol 116; PSA 2.39; HOS
glucose 0.26 and nicotine 0.03; hepatitis C screen negative
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Case 3
APS cardio received
1/14: chest pain requiring hospitalization due to abnormal EKGs; nuclear scan, TM and echo ordered
2/14: TM spect exercise 13 minutes, 17.2 METS, peak BP 158/78; no ischemia
2/14: echo MVP with evidence of mild MR; EF 68%
3/14: follow-up; some chest pressure but feeling better; patient reassured
4/15: echo for chest pain; LV diastole borderline at 48mm; EF 70%; LVPW 1.6 (mid to high substandard); IVSd 1.2; mild LVD; mild TR
APS PCP received
6/14: colonoscopy done and small polyp removed at 20cm; pathology pending
Would you make offer subject to pathology report?
(cont.)
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Deciding on the APS
What is the range of risk encompassed by the missing APS?
What is the pre-test probability of disease (and rating) in this individual?
Do we already have appropriate cover from non-synergistic rating?
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Deciding on the APS
What is the range of risk encompassed by the missing APS?
What is the pre-test probability of disease (and rating) in this individual?
Do we already have appropriate cover from non-synergistic rating?
When can we do without the path?• Same questions!• Do we have a detailed, credible description from oncology (or PCP)?• Does the passage of time give us confidence?
o Does commentary (or lack of commentary) in APS give us confidence?
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Case 4
27-year-old male, non-smoker, $500,000
MIB hit for HTN and DM (within second year prior to application)
5.10.237; 121/77
Client assessed Table F for labs and build
Insured admitted: PCP LOV 11/14 for routine check-up; also admitted to check-up 3/14
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Case 4
Labs• Glucose WNL• A1c 6.7• Cholesterol 233• Rx check consistent with known history• Underwriter noted MIB code and indicated Metformin initially prescribed in 2008,
making the age/duration of the DM +150
Would you require PCP records to offer here?
(cont.)
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Deciding on the APS
When are primary records adequate (in lieu of specialist records)?
Should we request APS on very high substandard cases?
“Was at table 12, ordered additional records, declined.”
Does face amount matter?
A couple of quick hitters
Multiple Impairments
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Comorbidity, Synergy, Causality
When is the last time you saw a case with a single impairment?
Comorbidity: when two or more illness occur within the same person; this also implies interactions between the illnesses that affect the course and prognosis of both
Synergy: the working together of two or more things (muscles, drugs or diseases, for example) to produce an effect greater than the sum of their individual effects
Causality: first is understood to be partly responsible for the second, and the second is dependent on the first
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Comorbidity, Synergy, Causality
Impairments – multiple
We don’t want to rate twice for the same physiologic process
We can’t ignore one process adversely affecting the mortality of another
Medical research is more oriented towards short-term treatment rather than natural history of disease combinations
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Comorbidities with Obesity65% of obese patients have either type 2 diabetes, and/or hypertension and/or hypercholesterolemia
Source: NHANES III
Htn only, 20.6%
HChol only, 15.2%
Type 2 DM + Htn, 3.7%
Type 2 DM + Hchol, 1.7%Htn + Hchol,
16.7%
All 3 comorbidities,
4.7%
None of these comorbidities,
35.4%
Type 2 DM only, 2%
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Coronary heart disease
Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome
Gall bladder disease
Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome
Gout
Stroke
Diabetes
Osteoarthritis
Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate
Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis Hypertension
Dyslipidemia
Cataracts
Skin
Idiopathic intracranial hypertension
Severe pancreatitis
Phlebitisvenous stasis
Slide from Dr. S. Klein, Washington University
Medical Complications of Obesity
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Multiple Impairments
Fully Blend Debits
Partially Blend Debits
Sum Debits
Sum + Additional
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RGA Approach to Multiple Impairments Blend? – no medical relationship between two impairments, or commonly associated
without known worse prognosis but NEED to review how condition was priced• Best example – MVR rating plus medical impairment• There are exceptions even to this
Partially Blend – limited interaction between the two impairments• Examples – impairments that affect different organs but not necessarily each other
o Valvular heart disease and hepatitis
Sum Debits – clear interaction where one impairment affects the prognosis of the other• Coronary artery disease plus stroke
Sum plus Additional or Decline – true synergism; the combination represents much greater heightened risk than either impairment alone. May have been excluded from study due to exceptional risk.• Diabetes and coronary artery disease• OSA and CAD
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What Do You Think?
CAD and Depression
Osteoporosis and hepatitis
Alcohol and narcotics
Diabetes and thyroid cancer
White matter changes (on brain MRI) and smoking
RGA’s Medical Underwriting Philosophy
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RGA – U.S. Medical Team
M.D.s• Sharylee Barnes – Internal Medicine• Elyssa Del Valle – Internal Medicine• Lisa Duckett – Geriatrics• Valerie Kaufman – Cardiology• Dave Rengachary – Neurology
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RGA – International Medical Staff
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RGA’s Medical Underwriting Philosophy RGA’s underwriting manual is a physical manifestation of our philosophy
• Provides guidance on an extensive variety of both common and rare impairmentso Highly detailedo Limited educational component
Developed by the Manual Review Committee• Includes medical director• Chief underwriter/senior underwriters/international underwriters• Line underwriters• Technical experts
Manual is evidence-based• Developed with input from experience studies• Forward-looking
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Development of Medical Philosophy
Desirable attributes for doctors• Open-door policy• We adapt to your workflow (cases, phone, Lync, e-mail, etc.)• Consistency of approach to risk• Stable over time• Competitive• Driven by experience and research, but also influenced by market factors• Easily understood and explained• Priced accordingly
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Key Principles of RGA Medical Underwriting Philosophy
We are consultants – the underwriter “owns” the case
Timely service
Avoidance of excessive requirements “FIBO”• If at all possible, make offers based on present evidence
Avoid being risk-averse• Deep and broad experience with complex and/or rare conditions
enables knowledgeable risk selection
Clear communication and documentation
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Development of Medical Philosophy
Desirable attributes for underwriters• Prefer UW appraisal questions to be short, focused, with rating suggestion• Let us know about any rating on the case (even if unrelated to the question)• If you PP, know the requirements for reconsideration• Reference page number on anything that you would like for us to review• Try to use abbreviations used by your peers• If you have a question or get pushback, first check with doc who did the case • No doctor shopping but can ask for second opinions
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