COVID-19 FAQs to help you answer client questions

PHIL KAUFMAN: Good afternoon, everyone. I'm Phil Kaufman, I'm the Chief Operating Officer for UnitedHealthcare employer and individual. We hugely appreciate you being here with us again today. We’ve got a lot of really good content for you. As usual, we are going to have Craig Kurtzweil lead off on some of the data within the space today. He’s got a lot of really interesting information on within the population who's been vaccinated, who hasn’t, what we're thinking on breakthroughs. As usual, we have Dr. Rhonda Randall with us who's going to give us some insight into both some of the recent developments on the clinical side related to COVID, as well as how we think about catching up on all health, non COVID related, which we think is a really important dynamic. A few housekeeping items, the call is recorded today. We’ll send out a replay through our various audiences, UMR folks, you can get that from your UMR rep. We do have a broad group of individuals on the phone today, some of the content we cover will be more applicable than not to others. And then there will be a facilitated Q&A session at the end. As usual, we would really encourage you to enter your questions into the box. We do our very best to come back round and get those at the end. Once Craig and Dr. Randall give their updates, I'm going to give you a little bit in terms of our view on the potential Biden vaccine mandate. I'll talk about the updates to CAA and transparency. And I'll talk about what we're doing is an organization around vaccine passports. It wouldn't be complete without our legal disclaimer, which you can see here on the screen, I'm not going to read it word for word, but just want to emphasize to make sure that you know, this call does not constitute formal legal advice and you should be checking with your legal and or clinical resources that you have within your organization. Before we get too far into the agenda, I just want to do two things. Number one is I want to emphasize that we are, compared to prior calls, we're going to go pretty deep on the data today. And we're going to show you a lot of information and we think some really good insight. But we also want to be careful, especially in this day and age that our numbers are not 100% accurate. And you'll hear Craig give some caveats as we go through this. They’re directional, but we think they're directionally very good and we think they deliver some very important insights. So we don't want to hesitate from showing them to you. But we also, frankly, don't want people screenshotting them and dropping on Instagram and everything else like that and saying, hey, UnitedHealthcare says. You know, we do like everyone do the best just to try to get the best data and information available to you and we're going to show that to you today, but I think it's important to have context around it as well and we'll try to deliver that as we go through the call. Number two, I just can't start again without thanking all of our providers and clinicians, many of whom are also clients and some of which may be on the phone today for all the really good work that they've done. I want to thank our broker and consultant partners who have been tremendous through this, helping to navigate a really complex space. You'll hear more of that today as I talk about a lot of the additional regulations, whether it be around transparency, or the CAA, or now potentially a vaccine mandate. So a lot of good partnerships around the horn. So we appreciate that. I think with that, Craig, I'll hand it over to you.

CRAIG: Thank you, Phil. And as Phil mentioned, we thought it'd be a good idea to start with some of the data and what we see around the pandemic. Obviously, a lot has changed since last time we talked so wanted to get everyone up to speed with what are we seeing across the US, across the globe and more specifically, what are we seeing within the UnitedHealthcare data. So on the first slide, we take a step back and look to see what's happening across the United States. And as you can see what the Delta wave over the last eight weeks or so we have seen a ramp up and COVID cases, positivity rates and mortality. But especially in the last two weeks, we've seen some changes. We started to see that the rate of the pandemic has started to slow, the spread of the disease has come down over the past couple weeks, the positivity rate is starting to subside, mortality rate remains a lagging indicator, so we are seeing that starting to ramp up across the population. But that again is a lagging indicator that we would expect to start to see come down if cases continue this downward trend. A little bit into the where do we stand as a country, across the globe, on the next slide, just a quick comparison of how the United States stands when you compare against cases for 1 million are looking at mortality and testing and vaccination rates. And so if you start in the upper left, you can see from a case perspective, we have the second most cases per capita in these top countries that I analyzed. That’s due to a number of different factors, but in the lower left, you can see that one of the big factors is we're testing a lot. We’re in the top five when it comes to actual testing that we're doing per million. So always keep that in mind, if you test more, you find more. And that gives a bit of perspective of where the US stacks up from a case perspective. But on the right hand side in the upper right, you can see mortality. We’re the 10th leading country, unfortunately, when it comes to mortality associated with COVID-19. And then finally, I know we're going to talk a lot about vaccines today, but if you look in the bottom right, you can see from a vaccination perspective, the percent of the population having at least one shot being administered, you can see that the United States is currently ranked 16th among these countries. So an interesting perspective of kind of where we stack against other countries and obviously these are changing at a rapid pace during this delta wave. The next view gives you a quick look at where's the United States at today. So a similar map that we've been showing you during the pandemic and you can start to see, the darker the color, the darker the red and the darker the blue is where we see the highest prevalence over the last week. And you can see that we've seen this shift from Missouri down into Arkansas and to Texas, and then started to head east around Mississippi, Alabama, and Florida. But in the last week, it's really about what's happening in those middle states, West Virginia, Tennessee, North Carolina. North Carolina, for example, has seen an 83% increase in the prevalence of the disease a week over week. We’re also starting to see up in the mountain states, in Montana and Idaho, in those populations starting to see obviously smaller populations, but a rapid spread out within those populations. And remember that when we come back and talk about vaccination rates and there's definitely a tie up between the two here as well. On the next view, we have a quick glimpse of what we're seeing across the pandemic today. So this is UnitedHealthcare data and as we look at key industries, we stack up what's the average prevalence rate of COVID across those industries, and what's the admission rates that we've seen across those industries as well, just to give you some perspective of kind of where you stack up. And there's obviously some connection with higher or lower prevalence based on the work type and the workforce and the type of industry that you're part of. So wanted to make sure they gave you the some of that context. And then the right hand side, I'm getting a lot of questions from a lot of individuals around some key stats around COVID. Looking at the average cost of COVID, an average patient in our system is looking at about $2500 or so. The average COVID admission costing around $40,000-50,000. Obviously, that varies across the country, but that's some average amounts. Overall, we're seeing about 6% of COVID cases resulting in an admission, and about a third of those are requiring an admission directly into the into the ICU. So obviously, we have accumulated a lot of data during the pandemic and that hopefully that’ll give you some perspective of some benchmarks of what we're seeing, again, at a country level and obviously results will vary when you look at specific regions and specific industries.

On the next slide let's come back and look to see how is the United States doing and kind of come back to our chart where we combined the experience for known COVID, the percent of people that have had one shot or partially vaccinated against the percent of people that have had one shot or have been fully vaccinated. This is data from the CDC that allows us to kind of look to see who has protection, and we know that vaccinations offer more protection than natural immunity, but we know they both offer some sort of protection. So as you start to stack these up as a country, we’re at over 75% of the population having some sort of protection. It's actually, if you look at actual COVID, because not as many people were tested and found positive for COVID as actually had it, we’re well above 80% as a country and some of these states, Rhode Island, Massachusetts, Connecticut, were above 90% in some of these states if you do this math. So this has a lot to do with what we're seeing as far as the spread of Delta and why some states are feeling the pressure right now from COVID and other states aren't in line of fire, at least at this point. And I think the next slide kind of brings that home. As you start to look at the trend during the Delta wave, there's basically kind of two parts of the country. As I stack up the top 10 vaccinated states against the bottom 10 vaccinated states, you can see that both have seen increases. We’ve seen increases in both those states from both a case perspective and a mortality perspective. But on the far right, as you look at the data from July that we've seen, basically the top 10 vaccinated states performing about half of the rate of increase in mortality and in cases compared against the bottom 10 states from a vaccination perspective. So over the past couple weeks, we've seen some steady declines in both of those for those top 10 vaccinated states. So we'll continue to monitor that because as we start to translate this into how are we leveraging this data to kind of help your populations and to help your communities. We're using this to kind of begin to have a broader education effort around the value that vaccines have on a population.

On the next view, we dig a little bit deeper into the impact fact that vaccines can have. And so this is UnitedHealthcare data and as I start to look at this, I can start to segment our population into those that are vaccinated and those that are unvaccinated. And just as a caveat, we have this in the footnotes but just note that when I think when I say vaccinated, unvaccinated, this is my view of the data, I don't have a complete line of sight into everybody that's been vaccinated, because there are some people that get vaccinated and there's no claims that are being submitted and so there's a bit of a gap in some of the data, but it's the best I have and I just wanted to give you as complete a view as I can into what we're seeing across these populations. So keep that in mind as you look at the next couple of slides. In this view, you can see we bucketed, both our Medicare retirement population M&R and our E &I or commercial population and looking to see what percent of our admissions during these last couple of months have been driven by the population that was vaccinated, was fully vaccinated. And you can see in the E&I population roughly right around the 1, 2 ,3% range over this entire time period. So 97 plus percent of the time, our COVID admissions are driven by the unvaccinated population. And the Medicare retirement population is a little bit different. We've seen it started around that same range, but it started to escalate as you get into the last few weeks and few months, where they're approaching 15, 20% of admissions, driven from the vaccinated population. So definitely different experiences and some of that, and I'm sure Dr. Randall will get into some of this as we talk about why our boosters necessary and things like that, but some of those M&R individuals were vaccinated very early in the first wave. And so we're starting to see as time goes on, that percent of COVID admissions driven by unvaccinated is starting to deteriorate a bit.

On the next slide, we look a little bit further into how do we start to cut and slice that population, again, percent of admissions, COVID admissions that are driven by the vaccinated population. And so if you look into the 31 to 50 population and younger, it's a percent or less, so 99% of all those COVID admissions are driven by the unvaccinated. As you get older, you start to see that rate kind of creep up 95%, 90% and it starts to shift a little bit as there's a little bit more of those cases that were vaccinated that are needing to be admitted for COVID. And at the end of the data, on the far right, you can see that 2.3% again of the commercial population that's being admitted are part of the vaccinated population. 98% of the COVID admits are for the unvaccinated population.

On the next page will look a little bit further into some of the comorbidities. So what do we know about some of those cases, those adverse COVID admits, that are that are driven by the vaccinated population? Well, it's definitely skewed towards the vaccinated population with comorbidities. So if we look at those that are obese, those that are diabetic or those that have hypertension, you can see that that rate of COVID cases requiring admission for the vaccinated population basically doubles across each one of those groups. So age has a lot to do with it, the time that you got your vaccine and the comorbidities associated appears to have an impact on the rate of admissions for the vaccinated population.

On the next view, we take a glance at what's happening, just broad sort of cases that have been fully vaccinated and have a subsequent COVID-19 diagnosis. And so what we see here is that within the employer and individual population were at 0.1%. And within our Medicare and retirement population were at just about 0.3%. So vast efficacy across these the vaccinations, we're not seeing as many breakthrough, quote unquote, cases. They obviously make the headlines and make the news. And we know that this is a little bit underreported, because I don't know of all the vaccinated population, but still very high rates of folks not having subsequent COVID-19 cases after being fully vaccinated.

And then in the next section, I'll take just a quick look at what's happening across who is getting vaccinated. So again, with all the caveats that I only know what I know, as far as what's coming through in claims data, but using that I can start to cut and slice the population into some different demographics. So if we look at it, this by age band, you can see for example, that definitely ramps up the people getting vaccinated are definitely the older population with a bit of a gap in that 20 to 29 year old population. I'll come back to that in a little bit. On the right hand side, if you look at this by life stage, who's not getting vaccinated, it's really the young families and the young singles that are eligible but aren't choosing to get the vaccine at this point at nearly the high rates that we're seeing with the empty nester population.

And if we take a look at conditions on the next view, so the people that with chronic disease that are high risk of potentially severe outcomes associated with COVID, you can see that there's definitely higher rates of vaccination rates and those diabetics, cancer patients and so on, we see some higher rates of vaccination. But as you get into some of the far rights, for example, maternity and pregnancy, we see that vaccination rate start to dip, with some hesitancy with folks that are dealing with those conditions as well.

And then finally, the next couple slides just look at some different views of the population. And so we’ve looked at derived income and just to be clear, we don't collect income values on anybody within the population, but using external data, were able to look at views of zip codes and those kind of algorithms to get a derived value associated with income, and in next view we'll talk about ethnicity. Just know we have tested these, and they're not 100% precise, obviously, but they give us a pretty good lens into occupation across the group like that. And so across our business, we can start to see that if we look at income, there's definitely a skew here. It trends from left to right. The higher income population has a higher degree of vaccination. And on the next slide, if you go back one slide, if we look at the ethnicities, you can see that there's definitely some cultural differences. Here, we see the South Asian and East Asian population have higher vaccination rates. And as you move into the Hispanic and African American groups, we see lower vaccination rates. And I'm sure this is this is playing through in some of your data as well.

And then finally, as we know, the COVID has had a ripple effect across the healthcare system. And so on the next slide, we take a glance back, we talked about this a few times ago. But looking to see that obviously the impact of abatements and people not going to see the doctor has been immense. We saw huge dips in wellness screenings and mammographies and so on in 2020. In this three year view, you can see how things have changed from 19 into 20 into 2021. And basically, in 2021, we've gotten back to 2019 levels. Now, that's not enough to make up for the big dip that we saw in 2020, but at least we've gotten back to a quote unquote normal level of these kind of services. We need more than that to make up for the dip that we saw in 2020, but at least it's a start.

And then on my last view, just as we think about the pandemic, one of the things that has obviously changed is that flu is basically nonexistent for the past 18 months or so. As we can see in the bars, that's the prevalence of the flu, the line is looking at the incidence associated with flu shots. So as we ramp up in our in the fall season here, think about this for yourself and for your populations that you manage, that there hasn't been a lot of flu across the country and there is a necessity to make sure that now that we're out and about and with people that there's some exposure to that.

CRAIG: My friend, Dr. Randall.

DR RANDALL: Thank you, Craig. Very good information to share here. And I'm going to take it a little bit further, so beyond the data that Craig shared with you and layer on some of the pieces around the clinical insight. So first of all, I think everyone's always interested in an update on where we are globally and domestically with vaccinations. So we will always start there. There are two ways toward herd immunity. The safest way is through immunization and the unsafe way is through infection. So where we are sitting at in the United States right now, we have 386 million doses of vaccine administered, globally just shy of 6 billion vaccines administered. So we always have to remember when we look at this data, although we're mostly focused on US data in this call that it is a global pandemic and to come out of it we really need to focus on what's happening around the globe and in all communities. So some notable information since the last time we met on Friday, the FDA’s committee on vaccines met and recommended a third shot in a series for those over the age of 65, for frontline health care workers and for those who are immunocompromised. Some people are calling that a booster shot. I have to say that I very much think about it as the third shot in a series. If you think about many of the vaccines that we've all had since childhood: measles, mumps, rubella, polio, tetanus, and I could go on, hepatitis. Most of those require 2, 3, 4 shots in a series. And it is looking like in order for those more vulnerable populations to have full immunity, longer immunity and a good B and T cell response that a third dose is necessary. There was also a sub heading in that vote on Friday that there's not enough data yet on a younger population and whether or not they will require three shots. So I want everyone to recognize that it wasn't because the data was weak, it was because the data isn't sufficient yet. The vaccine wasn't available to people under the age of 65 until a little bit longer, so it's going to take some more time for them to gather that data and review it, so I anticipate that we'll see that in a few months. The next thing on the horizon with the vaccine is a pediatric vaccine. Pfizer published their study just within the last couple of days, and I expect them to go to the FDA for ages 5 to 12 within the next several weeks. We don't have a hearing date for that yet. And then the other two vaccines that have authorization in the United States are being studied for population under the age of 18. So I also anticipate that we will start to get insight on the data of Moderna, followed by Johnson and Johnson and Janssen in a population under the age of 18. But what's really clear in all of the data that we have been looking at, that we've shared with you over the course of the last nine months or so since vaccines have been available, is regardless of the alpha viral type or the Delta wave that we can see a marked impact on serious illness requiring hospitalization and mortality rates for the population that have been vaccinated. And along with that, for plan sponsors come some significant cost differential in those who are vaccinated versus those who are not. So right now, Pfizer has the full FDA approval for 16 and up, EUA down to 12. And Moderna and Johnson and Johnson and Janssen with the emergency use authorization as well.

So I want to move to the next slide. Lots of talk around variants. Coronaviruses mutate. They always have. The typical, common types of coronaviruses mutate. The good news is that most of them are slow mutators. The WHO, this is a list that you're seeing here, variants of concern and variants of interest. The Delta variant is representative of the majority of cases circulating in the United States right now. One that you might see on that list now, it now has a great name is the new variant. There are… Most states, I believe about 49 of 50 states have found at least one case of the new variant. It has some additional mutations in the spike protein which makes it a very interesting one that's being watched. But right now the Delta variant is so highly transmissible that it really is the dominant variant circulating today. We'll continue to watch this along with the reports from the WHO and the CDC. Let's move to the next slide.

So updates on treatments. There have been some additional monoclonal antibodies that have received emergency use authorization. There are monoclonal antibodies that are approved for outpatient treatment for children 12 years and up who are at high risk and adults who are at high risk of complications because of their age or co-morbid diseases. Those monoclonal antibodies do have a significant improvement in reducing the risk of hospitalization in COVID positive patients who are at higher risk for developing serious illness. So whether vaccinated or not, getting those individuals to that treatment early in the course of the disease is very important. There's not a significant amount of other notable treatments that have emergency use authorization or approval since the last time that we met. But there is a significant amount of work in this field, actually on the treatment side, multiples of what's happening on the vaccine side with COVID predominantly focused on getting to an outpatient treatment that can be used either for avoidance of serious disease, or even prophylaxis, much like we do with things like Tamiflu during flu season. So that's what I'm watching for there.

And then I want to move next to what we're seeing and what we're hearing on the ground, what we're seeing in our data. COVID is not the only circulating virus right now. We are now into flu season and I'll spend a minute talking about that here. But I also wanted to mention one if you haven't heard, RSV, this is a disease, a viral disease that typically affects children, in particular infants, more so in the winter months. So we usually see this in the very winter months, November, December, January, February. We started seeing RSV this year in those kids in April. It’s a respiratory virus causes wheezing like symptoms. Sometimes those children need to be hospitalized and given medications to help that help them with their breathing as they get over the virus. It can be very serious in premature babies, for example, but what's concerning is that we saw it earlier this year. So we started to see it in the summer months and that's not typical. And so we're starting to see that come down. But that was a change in what we saw in infection patterns this year. And another thing we are starting to see the emergence of influenza. Several states are reporting cases of influenza. You saw the data that Craig showed you earlier. It's early in the flu season, but this is the time of year for you and your family and your employees to get their flu shot. Another thing that I'll mention here is flu shots are approved six months and older. The goal for herd immunity against influenza is to have 70% of the eligible population vaccinated against the flu. In 2019, which is the most recent data that we have available, we had under 50% of the United States vaccinated against the flu. And the younger you go, the less likely individuals are to have their flu shot. And I want to remind everyone that although we are seeing increases in cases in COVID in the pediatric population and hospitalizations, predominately because of Delta wave is much more contagious, that influenza is a more deadly illness in children. So it's a really good reminder for your families and your employees, for everyone to get vaccinated for the flu, including children. So partnerships that you can do with school districts, etc. to have those flu shots, easy to get, maybe on a school campus, for example, can be very helpful in this regard. We do a significant amount of reminders to our members to your employees and their families around getting their flu shots through many different channels. And your account management teams will be working with you on additional communications that you may want to send and share with your employees around flu season. One of the reasons this is more important this year is we were fortunate last year, we saw a very mild flu season but because we had that break, in addition to the vaccines that we normally see, we didn't get that unsafe natural immunity through infection. So, public health officials are concerned that this flu season may be worse than the 2019 flu season. So that's going to be something to watch, but we can impact it with flu shots. And we do have antiviral treatments available for influenza as well. So let's move on.

Next, I want to share with you some of our data around returning to health and we'll go to the next slide as well. And one more, please. Okay, I'm sorry. I thought I had a slide there on return to health. So we'll sit on the return to health one for a while. Craig shared with you some of the data on where we have made progress and where we need to continue to make progress with with regard to return to health. As far as childhood immunizations, cancer screenings, and others. Those are areas that we're really watching. We are seeing that 2021 is significantly better in most of those categories than 2020 was, but for the most part have not returned to 2019 levels. We have done particularly a lot of work with cancer screening around non-invasive tests, like FIT, for example. And we've seen that be a really good member experience. You don't need to go into an office, you can do the tests very easily at home without the preparation. And if you do have a positive test, then the colonoscopy that that needs to be done after that is still covered as part of the screening. So we have seen some nice improvements in that one. But there are childhood immunizations, as we have kids returning back to school and back to the classroom, there's an important one that we're watching. And that's an opportunity for schools, pediatricians, family physicians, health plans, and plan sponsors to really focus on getting those kids back to care.

Right, I want to spend some time next on behavioral health and share with you some insights that we're seeing that concern us. So disproportionately with behavioral health, we have seen an increase in mental health crisis in our youth, in adolescence and in young children. We have seen that adolescents are reporting one in four that their mental health is worse than it was before the pandemic. And for parents of school aged children, one in five reporting that their mental health is worse. So important to note. Other things that we are seeing in our trends around mental health is the female population is utilizing health care services, reporting rates of poor mental health days, reporting rates of depression higher than their male counterparts. And there certainly can be a number of reasons for that, but it's something that we wanted to bring your attention to that there are a handful of groups that we see have been disproportionately affected: youth, women and the elderly. And so I think we are probably getting close to time here. But some of the things that we are are doing about that is really what I want to make sure that we reinforce from self help through Employer Assistance Program, through our formal behavioral health programs and telebehavioral health which has stayed at a very high utilization rate since the pandemic started. But also things that we can do as employers and in our communities to recognize some of those simple signs in kids, for example, they may change their academic performance, it may change their sleep patterns, they may be more withdrawn, you may see things that don't typically look like just sadness and things that you would see around anxiety and depression. So things to watch out and keep an eye out for and the conversations that you have at work and and making sure that people know where the resources are.

PHIL: Great, thank you so much, Dr. Randall, hugely appreciated. And, just quickly here you can see the data on the screen here of some of the visits. And I think we make a lot of this material available post the call. And then just to emphasize with what Dr. Randall said in this last page here, we're really trying to get aggressive in our outreach to places and members where we think there are vulnerabilities and try to make sure they know the all the right educational materials are available and ready to go. So it's a place that we think is really important. And in I think Dr. Randall said it really well, it’s not just about COVID. There's a lot of other challenges out there, whether it be mental health, flu, other physical conditions, and we're really focused on that return to health dynamic in your populations. I'm going to shift gears here and we'll hit a little bit on the policy side. And I'm going to start with a discussion of President Biden's executive order that was issued several weeks ago on requiring vaccination for employers of 100 or more employees. And the way it is written, there's really kind of three different tenets of this. The first is if you are a provider, and I didn't see any size specified there, you have to have all of your employees vaccinated. Number two, if you are an employer of over 100 employees, you need to either have your employees vaccinated or have them tested once per week. It's important, I'll come back to that. Number three, at least, the way the rule was stated, was if you are a government contractor, you have to have your employees vaccinated, no opt outs. So those are the three provisions. Now, as soon as it's released imagine thousands and thousands of different questions, how are how is this going to be administered, everything else like that, and I'll go through a couple of things that I'm thinking about. But I did want to emphasize that the detail, and it's going to be an OSHA regulation, a temporary emergency OSHA regulation, that has not been released. I was hoping that it would be out by the time we had our call today. I have not seen it yet. My expectation is sometime in the next week or so it will be delivered. As soon as we have a chance to assess that, as always, we will try to give you our best insight. In the absence of that detail, I'm just going to give you a few of the things that I'm thinking about. And by the way, we are emphasizing with the administration to try to reduce the administrative burden on your behalf. Number one is that the verification of this is very much a challenge. And we don't want either the employer or the insurance company to put in between have kind of challenging the employee of like, well, did you really have the vaccination or not, show me proof. So there needs to be a reasonable standard of how we collect, track and monitor the data. So the verification piece is a challenge. Obviously, it's an administrative challenge for all of you to be able to track who has been vaccinated and not to be able to track, hey, has this employee who refuses to be vaccinated been tested every single week? So obviously, that is a challenge. When it comes to the testing piece specifically, again, another very complicated dynamic. If someone refuses to get vaccinated and they need test every week, do you still need to do that if it's a work from home employee? That doesn't really feel like it makes sense. Are there opt outs for either religious or medical reasons? There could be some legitimate medical reasons and how do you track and measure that? So there's both that burden, there's a cost burden of that, as well as an administrative burden. Just to be clear, we feel strongly that if there's going to be a vaccine mandate out there and you say, hey, if you don't get the vaccine, then you have to test but we don't think that should be the cost burden of the employer. We don't think it should be the cost burden of the insurance company. If that's going to be the mandate, we think that the government should be making either test kits available or have some other mechanism to be able to pay for that. Finally, there's the dynamic, which you saw a little bit earlier, and these are important points, so I want to emphasize them again, which is, if you look at our data right now, and when we say, when Craig says commercial population, typically what that means is, you're typically aged under 65. And in that population, the really good news is, is that if you've already been vaccinated, there's only a very small chance - 3% or less - that you are going to be hospitalized according to our data. So within that population, so far, so good. It doesn't really seem like a booster is necessary yet. However, if you look at that 65 plus population, you can see there's an increasing number of hospitalizations of people who have been vaccinated. And so we think for sure, in certain populations, you're going to need a booster there. And as Dr. Randall, f we have time, we'll come back to later on, you know what, the data has yet to play out. We don't really know. This is all very new of how long booster immunity will last in a younger, healthier population. So to be determined. Bringing it back to a vaccine mandate, you know, is this going to be like a one and done? Or is it going to be like ongoing, because now you know what, yeah they’re vaccinated right now, but what about the booster? And how do you track that? So a lot of complexity in here. We will do our very best to, number one advocate for you. Understanding that I've seen on both sides of the spectrum here, I've got employers who have said, hey, you know what, this really helps me out because I was thinking about a mandate before and this helps me push it all the way to the other side of it, okay, this is completely unconstitutional and this creates a really competitive disadvantage for me versus some of the other employers and I've got a really tight labor market, I can't afford to lose people right now. So we understand there's a range of spectrums. Just know that our position is, hey, we don't want a huge administrative burden placed on all of you, the employers. We just think that's not right. And so to try to navigate our way through this, it'll be tricky. But know we'll give you the best advice that we have on this.

Let me shift gears a little bit from the vaccine mandate. And I want to talk about what I’ll call vaccine… In the public term, it's called vaccine passport. And if you go one more slide here. And again, I want to acknowledge that there are really strong opinions on this. There are people who really believe that having the passports is a violation of civil liberties, all the way to people who think that this is, you know, a way to restart our economy and our business and give people more confidence. At United we work really hard. We don't try to take a political view on this one way or another. We don't try to take a position. Our position is, Hey, you know what, if New York City says, you're going to have to have vaccine proof to be able to eat in a restaurant, we want to be able to provide our tools to our members, if they want it, to be able to do that. That’s our position on this and we'll continue to drive that. So it's always going to be at the option of the member. You never force people to do it. But it's an option there if it's available. And what you see here on the screen is some of what we've developed. I'm proud to say that this is all live. As we sit here today, this is for our UHC core customers. We are working to deploy it for our UMR and our All Saver population. But what you see here is on the left hand side is you see, hey, because we have the ability to reach into the pharmacy and get the record of whether or not someone's been vaccinated. You can see here on the screen, hey, we can show what vaccination you've had when you've had it. There's also a self-reporting capability here for you to be able to enter in, hey, if you got the vaccination somewhere else and we didn't pick up the record, you can scan your card, you can submit it, it will show here. As we roll this out, there's been their usual kind of hiccups, we continue to improve it, be patient with us. We've evolved that and said now actually, if we've got the digital record, and so you can't use the self-reporting for this, but if you have the digital record, and we'd be able to digitally validate that you've had the vaccine, we can actually produce a QR code. That QR code is compatible with services likelier with services, eventually, like European countries will require at least right now they're saying they require proof to enter the country, this should work for that. Certain theaters, stadiums, etc., have started to ask for this. So again, not taking a position on hey, is it a good thing? Is it a bad thing? But just saying if other people make that choice, we're going to start to produce tools to be able to have our members access this technology on their smartphones via their digital record, etc., to be able to use this. So we're pushing towards that. I have to tell you that I travel a decent amount and I've been in several places, I've actually used these, they've worked, so positive so far, in terms of, you know, the ability to kind of use these and show vaccination record.

The next thing I want to talk about is an update on some very significant what I’ll call regulatory items. And if you look back into history, August 20th, the Department of Health and Human Services gave additional guidance on both of these provisions. And its tri-agency FAQ 49. So a long technical name. But what that said was, if you look to the next slide, we've been talking about these two for a number of sessions, and you've got all what they apply to up here. But I just want to reinforce there was a number of delays. And so I want to reinforce here's what still planned to go into effect and here's what's not what's still planned to go into effect. But before I tell you what goes in effect, one other important caveat is that the agencies said hey, plans, employer plans or ERISA plans and issuers should use good faith and reasonable interpretation to meet the 11/22 dates. So they've been very clear that there's as long as you are making a reasonable effort to comply, there should be a decent safe harbor here. I think that's really important. The expectation of what we are still to comply 11/22 is as follows. The no surprise billing provisions, the independent dispute resolution, those are both really large and really important, meaning that if a member goes out of network to a facility, they're supposed to be held harmless. And now that becomes between the provider and the ERISA plan or the insurance company. So those two provisions are still planning to go into effect. Changes to ID cards. Just a reminder, that's at renewal. So if you have an existing ID card, and you're not a 1/1 renewal date, don't have to worry about it. But at renewal, you still need to make those changes to the ID cards. There’s still some improvements we need to make to our directories. They're pretty good today, just tightening up the speed and timelines of which we do some of the updates. Continuity of care, and some gag clauses around attestation and compliance. These largely don't apply to the United business, we've never really utilized gag clauses in terms of how we've negotiated with our providers. So those are the things that are still going to go into effect and there are going to be some costs associated with those. So I want to be clear that your account teams and account managers, particularly if you're a self-funded client, they will be talking to you in the next month or so around some of the increased costs that you're going to see associated with those. So for example, an arbitration fee, when one of these out of network negotiations goes through, it absolutely has to be going through an arbitrator. So that's a good example, there's costs associated with that. For those customers who are either what we call level funded, or fully insured, you don't need to worry about this as much. UnitedHealthcare will be largely complying on your behalf. There are some things that were delayed as part of this. And I think those delays made a lot of sense, because there's a lot of ambiguity, and frankly cost, tied up into these provisions. And between the providers, the insurance companies, employers, there just wasn't enough detail to be able to comply with these provisions. The things that have been delayed were the advanced cost estimates. So between, Hey, do we have to provide an advanced cost estimate upon request, or is that for every single service scheduled 10 days in advance? So looking at those different dynamics. The pharmacy and benefit cost reporting, the price transparency tool, the consumer price transparency tool. And then finally, on the transparency side, the machine readable files that had to become available, making public all the negotiated rates between the insurance company and the provider. There's a lot of implications in those last two. We don't have time for me to go deep in those today, but just know that we will continue to provide insight to you in terms of how that will change long term, the cost, the contract, and even the product within the space. So we'll continue to stay very attentive to that. I want to pause there, and just, well, but before I do just emphasize again, there continues to be a lot of guidance issued on this. So just know we continue to try to update our FAQ and as much information as possible. If you didn't hear an answer today that you're looking for, and I'm sure there's a lot going on in the Q&A chat right now. Please do make sure you talk to your account rep. It's their responsibility. It's my responsibility to be able to get you that answer. That's our job. So if you're not getting that from us, we're not we're not doing our job. So please make sure to be vocal on that.

PHIL: A few questions here that I just… I've seen a bunch in the chat and I'm just going to jump in on. And then, and I'll have Rhonda and Craig kind of join me back in on this. The first is some, you know, talk to me more about, hey, if you leave Craig's data and it costs so much for a COVID hospital admission, why don't you just differentiate the premiums? And why don't you just charge more to people who haven't gotten the vaccine than people who have? I covered some of this in a previous session, but I think it's worth reiterating, which is, for a fully insured product, it's actually not legal for us to do that today. The insurance regulators don't allow you to differentiate your premiums based on a specific condition. Now, it's possible, it's entirely possible that perhaps the Biden administration will offer new guidance that allows that so if that's the case, we will look at it but as we said, today, you can't do that. It is legal for you as an employer to offer an incentive or a penalty. There are a ton of rules around that, of like how much you could do, how you'd have to do it, the taxability, the opt outs, but it is a possibility and an increasing number of employers are looking at that. So if that's of interest to you, we suggest that you kind of come back to us separately, we can try to give you the guidance that we have, but there's a lot of there a lot other out there from a particular legal standpoint that you should be looking at. Dr. Randall, I'm going to throw a couple at you and they have to do with the intersection of COVID vaccines and flu vaccines. And I guess the first question is, Hey, can you can you do both of vaccines at the same time? Or do you have to wait?

DR RANDALL: It’s such a timely question. And if you would have asked me that question a month ago, I would have had a different answer. So earlier in the pandemic, while COVID vaccines were new, we hadn’t given them before, we really wanted to have more data and understand if there was a vaccine reaction, what was the cause of it. There was a recommendation to wait two weeks before or after getting the COVID vaccine and any other vaccine. Now it is suggested that COVID vaccines and flu shots can be administered at the same visit to different arms. So you know… And you know, you're going to have to weigh at an individual level and in consultation with your personal physician, if you’re somebody who doesn't have access to care, if you're not worried very much about a reaction from one of the shots, go ahead and get them both on the same day. And then there may be others where you and your physician decided, still prudent, to wait two weeks in between.

PHIL: Great. I'm going to keep going with you Dr. Randall. We've had several recent developments on boosters, or, as you may say, a third dose. But let's start with, there was some news today on J&J. And saying, hey, you know what, an additional J&J shot looks like it increases the amount of antibodies. And then after that, let's go to kids and the news that Pfizer looks like it says, Hey, one, lower dose, I think, is more… it looks like it's going to be effective for younger children and they're going to be applying for EUA approval.

DR RANDALL: Yeah, and this isn't surprising at all, you know, it's a very new pandemic, right, we've known we've known the genome of COVID-19 since January of 2020 and within 12 months, we had a vaccine and within just a few months longer than that we had three viable vaccines that received EUA. So now as we are further out from that vaccine administration, I think that we are learning and it's not surprising that the messenger RNA vaccines, particularly in populations that don't hold their immunity as long, in immunocompromised populations and older populations, for example, and then frontline healthcare workers who are exposed to this virus, you know, in their work all the time, that we would see that within a certain amount of months afterwards, you would need the second shot or the third shot in that series. It's still too soon to tell if we will need more beyond that. More time will need to be studied. You know, is this something that is going to need to be an annual shot?  There's suggestions that it's looking less likely, there are other suggestions that maybe we will. What we might see is five years down the road or many years down the road, like a tetanus shot, right, you may need a booster at some point in the future. But for right now, particularly the vulnerable populations, those who are at most risk of getting seriously ill, it is very likely that if they got the one shot, they're going to need a second. If they got the two shots, they're going to need a third. And then the pediatric population, you know, so in most cases and in all cases, pediatric dosages of vaccines particularly under the ages 12 are different than adults. So that's why it's important for moms and dads to not run out right now and try to get someone under the age of 12 vaccinated with adult vaccine, that's not the appropriate dose for them. Until vaccine is approved for kids under age 12, the best way to keep them safe is to get all of the household contacts who are vaccine eligible vaccinated. So mom and dad, get vaccinated, older siblings, get vaccinated, that is the best way to protect your kids until they're eligible for a shot.

PHIL: Great, thank you, Dr. Randall. There's a number of questions on the Biden vaccine mandate. And I'll do my best to just knock a few off. There was one: does it apply to 100 employees per location or just 100 employees as total? It’s written that it would be 100 employees in total. Does it apply to work at home, you know, versus like in office populations? We don't know yet. There's no clarification or definition in there on that. There were a number of questions on you know, do you think this is going to survive a legal challenge? And you know, these are the places where if my legal team was on, they'd say, Phil, don't answer that question. But I'm going to answer it, which is, I think you're likely to see a scenario in which you will have a huge number of legal challenges both at the state and the federal level, to whatever mandate is put forth. As an insurance company, and you as employers, I think the challenge is going to be the rule will be issued and will lower court say, well, you know, what, I'm not sure if it's legal or not, but I'm not going to take any action right now and I'm not going to make a ruling. And so there could be very likely like a period of time or let's say, if it goes all the way to the Supreme Court, there could be an extended period of time before you know is it constitutional or unconstitutional or not? So there's, it's not just hey, will it survive legal scrutiny, but what's going to happen in those lower courts? And will any of those courts actually prevent the rule from going into effect? So there's multiple layers of this, as I said earlier, that the detail’s not out yet. We will be watching this closely and as soon as we have more information we will be able to get it to you. Okay, there was a question here on elaborating a little bit on ID cards, and just confirming that what's changing on the cards, and then if your renewal is after 1/1 you just have to do it at the renewal date. So what's changing on the cards is some of the out of pocket max and the deductible information, it actually makes for a very crowded ID card just to prepare you in advance, but technically, we think we've been able to do it, but just confirming that you do not need to reissue your ID card. So for example, if you go past 1/1 and your natural plan, your renewal date is 4/1, you would not need to reissue ID cards until 4/1. Let's come back to the vaccine pass. And I just want to be clear on, there's a questions on, Hey, is it available on web, app, mobile? And so just one kind of quick clarification there. It's available on MyUHC.com. It's available on MyUHC.com via mobile web. So if you, you know, log in, it's not yet deployed on the app, which I fully understand is a shortcoming because you'd say, hey Phil, it's a whole pass, you want to use it on your on your smart device, I totally get it. It's a little bit harder to deploy the technology there. But what I would tell you is you can access it if you go to the website, just via like MyUHC.com, not via the app and via your phone, you'll be able to get there. You’ll be able to see it. But also note that you can print it out. So you can print those out. There's a print button, you can put it in your bag, you can carry it with you. And at least the places that I've been going that have required vaccination proof have taken that.

Okay, we've just got a couple minutes left, and I want to I want to respect your time. First, I want to thank Dr. Randall and Craig Kurtzweil, who as usual, are here presenting with me. I do want to emphasize that the mentee poll was up there. We love your feedback on these calls. We love your questions. We do try to take everything that we gather from you and we try to feed it back via your reps. And then finally just to close out today, I cannot tell you enough how much we appreciate you putting your faith in UnitedHealthcare, UMR, All Savers, to help deliver care on your behalf and your members. I will tell you that we work really hard to be able to give you the insight to run your business. But as you heard from especially Dr. Randall today, we work really hard to make sure your employees and their families stay healthy. And we really take this seriously. It's part of our DNA. And we're going to continue to work on that. All the data that we showed today, we work hard to take that data and to try to bring it back into how we're interacting, the messaging that we're using, how we're trying to get people to return to health, so it's not just about idle data. We take it seriously. We try to make a difference. So thank you for that. Hope you all have a great week. We will.… As soon as we have more detail on some of the other things, we will schedule another call soon.