Telemedicine Update for DBRA Members Dennis J. Riedmiller, CBC Riedmiller & Associates, Inc. Chartered Benefits Consultant September 29, 2015

“Mr. Jones the doctor will see you now in the office “Mr. Jones the doctor will see you now in the office. Well maybe not today”! Primary Care doctors – Calling all doc’s!!! Where are You? Your doctor is only in office 28% of the work week.

Projected Demand for Primary Care Physicians   2010 2020 Total primary care physician demand (FTE) 212,500a 241,200 Generalb 164,400 187,300 Pediatrics 44,800 49,600 Geriatrics 3,300 4,300 Primary care physician supply 205,000 220,800 Supply and demand (7,500) (20,400) a National demand projections presented in this report assume that in 2010 the national supply of primary care physicians was adequate except for the approximately 7,500 FTEs needed to de-designate the primary care HPSAs. B This category includes general and family practice, and general internal medicine.

What Is Going On? According to Centers for Disease Control & Prevention 1.25 billion ambulatory care visits in U.S. per year Estimated that 33% or 417 million could be treated through telemedicine According to National Association of Community Health Centers 62 million individuals in the U.S. have no or inadequate access to primary due to physician shortages According to Department of Health & Human Services, ACA has expanded coverage to 16.4 million of the 47 million uninsured Americans According to American Medical Association $734 billion, or 27% of all healthcare spending in 2011 was wasted due to unnecessary services, inefficient delivery of care and inflated prices

New Telemed Model - Active Platforms Telemedicine is uniquely positioned to bridge the supply and demand gap between physicians and consumers Fundamentally changing the way market participants access and deliver healthcare Eliminating traditional barriers and inefficiencies and empower thru healthcare marketplace According to Veracity Healthcare Analytics a client in 2012 with 150,000 members saved client $1,157 on average per employee. Return on Investment saved $9.10 for every $1.00 spent per member 92% of medical issues resolved which did not require follow-up The Towers Watson 2014 study suggests that 71% of employers with more than 1,000 are expected to offer telehealth services by 2017

2016 - The Future Has Arrived Telemedicine Dream in 1925 2016 - The Future Has Arrived

Teledoc, Inc. First telemedicine company to apply with the Securities and Exchange Commission for filing and approval as a common stock Stock price range $19 - $35 $18.3 total revenue 78% from 2014 11.5 million members from 7.8 million in 2014 a 48% increase $16.3 operating loss Total visits projected to be 520,000 – 540,000

Game Players Teledoc American Well 1-800MD, LLC Consolidation in the marketplace (Consult A Doctor, AmeriDoc, BetterHelp) Hospitals and multi-specialty group practices Dr. Phil – Doctor On Demand

Telemedicine Strengths Concept is acceptable Benefit Advisors “Channel Partners” are recommending to clients HHS promoting for Medicare/Medicaid Low Cost/High Value - $.70 - $4.00 EM/PM base costs Alternative to costly Primary Care Integrated technology platforms High-Quality Provider Networks Cost Reduction/Return on Investment Increases access to appropriate care Reduces use of hospital non-emergency care Less absenteeism Consumer Engagement Telemedicine is an “Emergent” industry

Telemedicine Weaknesses States are a patchwork of legislation Teaching employees how best to use medical resources Elderly have limited access to cell phones and computers Some Benefit Advisors slow to move Disincents rural hospitals to build more space

Phone & video consultations with Rx Phone & video consultations, short-term Rx limits Phone consultations only with Rx Consultations unavailable

Telemedicine Opportunities Trigger advancement in telecommunications TPAs integration into medical model $50 Billion+ industry in next 5 years Sets the stage for more IPO offering Capital infusion Return of investment, lower utilization Favorable utilization – 5% to 30% Adds to inventory of alternative providers (Physician Assistants, Nurse Practitioners, Retail Clinics)

Telemedicine Threats Legal field seeking new “victims” (no tort reform in ACA) Rx in connection with telehealth visits Evolving government regulation Insurance companies could make punitive Potential exposure to class action History of net losses and deficit of some telehealth companies Retention of qualified providers Demise of solo medical practices Primary Care group practice reduction of income Prospect of drug abuse State actions against business model

Opportunities of Telemedicine for Employee Benefit Advisors Addition to product portfolio Cash flow stream True plan advisor due to financial reporting Trend setter in industry Educational propensity to serve client Excellent alignment with wellness initiative Cost reduction for employees and families Wholesale model is aligned with traditional health and dental pricing Market entry into new entities, like Association accounts, Board of Directors, 1099, part-time or seasonal employees Some telehealth carriers offer retail products

Telemedicine is only for Large Employers or Entity Groups! Right? Not Really! “Money Follows Value” of any size!

Client Report Client located in rural Ohio, near Cincinnati Blue collar manufacturing 37 full-time employees/75 members (2.02 family size) Offered January 1, 2015 Reporting based on 8 months No co-pay to employee Fixed plan cost (Access Fee) is $4.00 PE/PM Broker commission is $1.50 PE/PM Client administration program cost - $1,188 15.5% employee/member utilization Net savings - $4,258 Average savings - $354.83 per employee Return on Investment – 374%

What If? What if I had a block of small group business based on 15.5% utilization with 1,000 employees that I service? Let’s do the math!

Agency Key Messages Broker annualized commission - $18,000 ($1.50 commission x 12 months = $18.00 x 1000 = $18,000) Aggregate client annualized costs - $48,000 - $48/Year/EM ($48 per employee x 1,000 = $48,000) Percentage of hourly payroll based on employee W2 wages of $50,000 would be $0.023 cents per hour (2080 hours per year / $48.00/EM = $0.023 cents) Aggregate annualized savings to client pool - $549,987 (Based on 15.5% utilization of 1,000 employees of $354.83 per employee per year x 155) OR (using 2.02 factor size 2020 - 313 x $354.83 family unit = $716,757

Outcome Message Broker annualized commission - $18,000 ($1.50 commission x 12 months = $18.00 x 1000 = $18,000) Our Agency covered overhead with little time investment Aggregate client annualized costs - $48,000 - $48/Year/EM ($48 per employee x 1,000 = $48,000) Offer a product at a low cost Percentage of hourly payroll based on employee W2 wages of $50,000 would be $0.023 cents per hour (2080 hours per year / $48.00/EM = $0.023 cents) Offered a product that costs less than 1% of payroll with a 374% return on investment Aggregate annualized savings to agency/client pool - $549,987 (Based on 15.5 utilization savings of $354.83 = xyz Agency is a proven leader in savings significant dollars for our clients Aggregate employee annualized savings - $354,830 XYZ offers a product that saves time and money, especially for those with high deductible health plans

TELEMEDICINE What are you waiting for??? Telemedicine is Here and NOW!!!