Medical Philosophy and General Discussion

Dave Rengachary, M.D., FALU

September 10, 2018

SVP and Chief Medical Director

US Mortality Markets

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Discussion Points

Risk Selection1

Valuation of Medical Information2

Multiple Impairments3

RGA’s Medical Underwriting Philosophy4

Risk Selection

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Approach to Risk

Risk aversion

‘Reasonable’ risk acceptance

Risk naïveté• Ignorance• Deliberate choice

Risk transfer/share

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Making a Decision

Manual

Medical knowledge

and referral

Pricing

Available tools

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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

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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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Questions?

drengachary@rgare.com

(636) 736 - 5827

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