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Telehealth –Theory, Practice, and PotentialSteve Abbs, MAAA, ASAKen Ehresmann, MAAA, FSATeresa Winer, MAAA, FSAModerator: Joe Allen Allbright, MAAA, ASASponsored by the Academy’s Health Practice International CommitteeSession 964:15 – 5:30 PM 2017 American Academy of Actuaries.All rights reserved. May not bereproduced without expresspermission.SOA Spring Health Meeting – June 13, 2017

Disclaimer 2Please note: The presenters’ statements and opinionsare their own and do not necessarily represent theofficial statements or opinions of any boards orcommittees of the American Academy of Actuaries, theSociety of Actuaries, the International ActuarialAssociation, Georgia’s Commissioner of Insurance,the State of Georgia, or other state regulators, nordo they express the opinions of their employers. 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Agenda 3Theory and PracticeStudy Review and Plan ConsiderationsRegulation 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Telehealth –Theory and PracticeSteve Abbs, MAAA, ASA 2017 American Academy of Actuaries.All rights reserved. May not bereproduced without expresspermission.SOA Spring Health Meeting – June 13, 2017

Discussion overview What is telehealth? What’s the theory behind it? How is this being used in practice? 5Going beyond the Contingencies article – a deeper look at some cases indeveloping and developed countries Barriers to implementation The future 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

What is telehealth?World Health Organization (WHO) Definition: 6“The delivery of health care services, where distance is acritical factor, by all health care professionals usinginformation and communication technologies for theexchange of valid information for diagnosis, treatment andprevention of disease and injuries, research and evaluation,and for the continuing education of health care providers,all in the interests of advancing the health of individuals andtheir communities.” 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

What’s the theory behind it? 7Theory is better health, more efficient care, andless expensive care. 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

The long sought-after silver bullet?Better Health1.2.3.4.8Remote monitoring allows for quickerdetection of potential health problems.Proactive wellness and biometricscreeningsFaster response in case of issuesAbility to connect to experts regardlessof physical locale.More Efficient1.2.3.Avoids the long wait times of physicianoffices or emergency roomsElectronic relay of information allows fornear instantaneous communicationLess Expensive1.2.Care where needed – not centralized.No need for commuting costsTelehealth care can be delivered for afraction of the cost of in-person care at anoffice or facilityKeeping people healthier morecontinuously lessens the chance of majorhealth issues later (“the wellness adage”)3.Lost wages during time away from work 14.Room & board 1 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

But that’s just theory – right? Jury is out on whether telehealth is THE answer going forward.However Prevalence of electronic communication looks to be a strongharbinger of rapid development and growth into this area; andThere are many cases of telehealth being put to good use in theworld today.Right now, the central issue seems to be: 9ACCESS, and the RURAL DIVIDE 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

How is this being used in practice?10 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Deeper look at some specific countriesDeveloping Countries 11IndiaChinaMongoliaDeveloped Countries IsraelUnited States 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Developing Countries 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

India13 Distance Healthcare Advancement (DISHA) Growth / Hub-and-Spoke Approach 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

India - General lay of the land A confluence of several factors interacting poorly: 2 1472% of India’s populace live in villagesMost specialists don’t want to practice in rural areas80% of physicians, 75% of dispensaries and 60% of hospitals arein urban areas!According to a PwC India consultant: “When it comes tohealthcare, India gets divided in two. Urban India hashealthcare centers of excellence, while much of rural Indiahas no access to basic healthcare.” 2 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

India - Distance healthcare advancement (DISHA) Launched back in 2005Mobile Teleclinical VanHigh-quality, low-cost diagnosticsLow income, rural communitiesThree-pronged delivery partnership 3 15Apollo hospitals – doctors for free consultationsElectronics Corporation of India – supplies satellite dishIndian Space Research Organization – puts the satellite in orbit 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

India - Distance healthcare advancement (DISHA)4,070 patients screened in the first 18 months ofthe pilot project Satisfaction among the villagers was high. However Connectivity problemswere encountered from/tothe van 4 16 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

India - Growth / hub-and-spoke approach Glocal healthcare and CSC eGov agreement: 5 Hub-and-Spoke approach: 1 17Will provide video consultations to people living in rural areasExpected to benefit 28% of the population with essentially no accessto physicians.Also 70% of rural populace with spotty access to quality medicine.Spokes are gateways to access “hub” technology and expertiseRead medical images remotelyDiscuss findings with patients 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

18 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

China Issue is partly urban-vs-rural, but also a long-running lack offunding for primary careIf limited primary care, where to go to seek care?Hospital 19(Not the best long-term solution)Telehealth is seen as a way to divert care away from theovercrowding and overtaxing of hospitals and theirresources. 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

China Growing mobile connectivity and economic growth are makingthis possible.What percent of China’s populace access the web through asmartphone?6 What percent of provincial level hospitals have their owntelehealth center?7 2083%50% 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

China - Cloud-based hospital 21Things are getting there!“Ningbo Cloud Hospital” 8Open platform connecting with hospitals, primaryhealthcare, specialistsSafe and standardized information systemDynamic health record for each citizen in NingboCloud Hospital App 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

China - Cloud-based hospital 22“Cloud Diagnosis Rooms”HypertensionDiabetesPsychologicalGeneral Practitioners 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Mongolia 23Most sparsely populated country in the world. 9Here the rural divide is enormousLocal doctors able to consult with experts in realtime without having to leave the exam roomAlso an online learning platform which includestraining materials and current clinical guidelines 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Mongolia 24Personal testimony from amother who has benefited:“We are very happy thistechnology is available in ourhospital, as it’s something wereally needed. It’s comfortingto know we can receive qualitycare in Altai without having totravel to Ulaanbaatar.” 9 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Mongolia25 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Developed Countries 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Israel 27Access is an issue here, as well.Israel is developed, but 40% of its 9 millionpopulace is concentrated in a geographical arealess than 10% of the country!Pediatrics 10Remote consultation by pediatric specialists 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Israel – Pediatrics 28Goal is after-hours carePhysicians have protocols concerning emergenciesand common conditionsAble to access electronic medical record, includingimaging and previous facility visit history.Emphasis is triaging immediate need vs. able towait until clinic hours 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Israel – Pediatrics 29High satisfaction (9.8 / 10) and 82% of sampledpatients reported a medical improvement in thenext day. 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Israel – Pediatrics Most interesting is a comparison of stress levels ofparents in face-to-face emergency room vs. telehealth:Findings were that telehealth helps reduce bothdistress, as well as the need for face-to-face counselingWhy?Phone conferencing: Sense of receiving attention and beingunderstood Video conferencing: Sense that the provider is aware of thepatient’s presence. 30 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

United States 31Mental Health initiativesTele-ICUsVirtual general practitioner visits 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

United States - Telepsychiatry North Carolina Telepsychiatry Network Adopted 32January 2014Even in a country as developed as the U.S., there isthe rural divide and the access issueAccess to mental health care is the biggest barrierto recovery for many people living in rural NorthCarolina 11 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

United States - Telepsychiatry 33Portable cart equipped with monitor, camera andmicrophone is rolled into patient’s bay or room.Establish secure videoconferencing link to psychiatricprovider site.Intake specialist explores patient’ssituation and discusses with otherfamilymembersPsychiatrist then interviews the patientandmakes recommendations to thereferring physician. 11 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Barriers to Implementation 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Barriers to Implementation TechnologyCompeting companies Need for high-speed internet connectivity SystemInitial investment / ramp-up time Providers not educated for new technology, or for rapidchange 35 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Barriers to Implementation Culture Legislation and Regulation 36Need provider buy-in of effectivenessJAMA Dermatology study and telehealth shortcomings 12All of telehealth’s current challenges (privacy, security, providerresponsibility, transparency, reporting) require re-working oflegislation.Potentially dealing with multiple state and federal regulatoryauthorities. 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

The Future 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

The Future Continual monitoring Population health management Slowing the spread of diseases such as West NilePublic Education 38Potentially identifying medical conditions early, and preventive treatmentEvery hospital/provider may have a person’s whole medical historyPersonalized outreach directly to consumerAbility of technology to interact in multiple languages 13 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

References1.2.3.4.5.39“Delivering World-Class Health Care, Affordably”; Harvard Business Review;November 2013“Telemedicine takes world-class healthcare to rural India”; ZDNet; June 25, 2008.“Unleashing India’s Innovation: Toward Sustainable and Inclusive Growth”; editedby Mark Dutz; World Bank Publications; October 15, 2007“Telemedicine in India: Apollo Story”; Telemedicine and e-Health; July/August2009“Glocal healthcare & CSC eGov join hands to take Telemedicine to rural India in abig way”; The Economic Times; January 28, 2017 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

References6.7.8.9.10.40“China Bets on Telehealth to Solve Its Healthcare Woes”; Yahoo Finance; 2015.Research on China Telemedicine and Online Healthcare Industry, 2015; ChisultInsight Co.; 2015.“China’s First Cloud Hospital ‘Ningbo Cloud Hospital’ Founded”; NeusoftCorporation; March 13, 2015“In remote Mongolia, telemedicine connects pregnant women to faraway care”;United Nations Population Fund; June 19, 2015.Waisman, Y. “Telemedicine in Pediatric Emergency Care: An Overview andDescription of a Novel Service in Israel”; Journal of Intensive & Critical Care; 2016 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

References11.12.13.41“Telepsychiatry in North Carolina: Mental Health Care Comes to You”;North Carolina Insight; March 2014“Review of telemedicine finds misdiagnoses of skin conditions”; UPI;May 17, 2016.“Public Health Education for Young Students Aided by Technology”;Journal of Telehealth and Telecare; April 2009. 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Telehealth –Study Review and PlanConsiderationsKen Ehresmann, MAAA, FSA 2017 American Academy of Actuaries.All rights reserved. May not bereproduced without expresspermission.SOA Spring Health Meeting – June 13, 2017

Discussion Outline Review of Studies VHA Alliance for Connected Care 43Assessment of the Feasibility and Cost of Replacing In-PersonCare with Acute Care Telehealth ServicesRAND Audit of The Home Telehealth ProgramDirect-To-Consumer Telehealth May Increase Access To Care ButDoes Not Decrease SpendingPlan and Pricing Considerations 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Review of Studies 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

VHA – The Home Telehealth ProgramCare to veterans through the use ofmonitoring devices placed in veterans’homes. Devices measured vital signs(blood pressure, pulse, and bloodglucose) and transmitted data tomedical staff for monitoring andintervention. Low Cost Alternative Reduction in IP Admissions (5 per100) Reduction in Bed Days of Care(BDOC)45ClassAverage 6-Month Reduction inBDOCNIC1.4CCM0.3HPDP0.4NIC – Non-Institutional Care PatientsCCM – Chronic Care Management PatientsHPDP – Health Promotion/Disease Prevention 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Alliance for Connected CareAssessment of the Feasibility and Cost of Replacing In-Person Care with Acute Care Telehealth ServicesStudy approach included thecollection of utilization data andcomparison of average cost oftelehealth services to theestimated costs of care deliveredin other settings Average cost of telehealth visit 40- 50 Commercial Savings of 126 pervisit Low Induced Utilization46AlternativeSite of CareDistribution of Alternative CareER5.6%Urgent Care45.8%Physician30.9%Other5.4%Do Nothing12.3% 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

RANDDirect-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease SpendingStudy approach includedclaims and enrollment datafrom CalPERS Blue Shield ofCalifornia health maintenanceorganization plan enrollees Average cost of telehealthvisit is 79 Telehealth visits are lessexpensive per episode but High Induced Utilization47AlternativeSite of CareDistribution of Alternative CareER/Physician11.8%Do Nothing88.2% 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Plan and Pricing Considerations 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Plan and Pricing ConsiderationsBenefit design Copays 49Higher copays may bewarranted despite lowerallowed costsCareful consideration toprevent inducedutilizationServices to include/exclude Acute, self-limitingdiseases may not bebest candidateMay have greater valuein care management(diabetes, chronic caremanagement) 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Plan and Pricing ConsiderationsMember Education Members Understandnewbenefits and optimalsituations Consider targetingcertain populations50Provider Education Providers Engageto promotebenefits Aid in identify targetedpopulations 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

16-101.pdfAlliance for Connected /RANDJ. Scott Ashwood, Ateev Mehrotra, David Cowling and Lori Uscher-PinesDirect-To-Consumer Telehealth May Increase Access To Care But DoesNot Decrease Spending Health Affairs 36, no.3 (2017):485-491 doi:10.1377/hlthaff.2016.113051 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Telehealth – RegulationTeresa Winer, MAAA, FSA 2017 American Academy of Actuaries.All rights reserved. May not bereproduced without expresspermission.SOA Spring Health Meeting – June 13, 2017

Presentation Outline 53Review of Federal and State activity, the CHRONIC CareAct, ASOP 8, and applicable lawState legislative process In GA – overviewState rulemaking, bulletins, directivesProcess for crafting NAIC Model RegulationsSummary 2017 American Academy of Actuaries. All rights reserved.May not be reproduced without express permission.

Active Federal Legislation on TelehealthHR1027 Hallways to Health-expanding demonstration program to provide and expand school based careHR 1084 Today's American DreamHR 1184 FAST Act of 2017Expand telehealth access to stroke servicesHR 1152 Care Veterans Deserve Expand telemedicine at the VAS 870CHRONICCareAct of 2017 forPaymentto improveareasmanagement ofHR 1255 CCMCARE actTelehealthinfrastructureremotepoliciesand underservedchronicdiseaseimprovementMedicare Act of 201-Improving healthcare including telemedicineHR 1369

Theory, Practice, and Potential Steve Abbs, MAAA, ASA Ken Ehresmann, MAAA, FSA Teresa Winer, MAAA, FSA Moderator: Joe Allen Allbright, MAAA, ASA Sponsored by the Academy’s Health Practice International Committee Session 96 4:15 – 5:30 PM