Transcript Underwriting A medical director’s perspective

Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Prevalence of Type II Diabetes
County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years:
United States 2004
Percent
www.cdc.gov/diabetes
County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years:
United States 2005
Percent
www.cdc.gov/diabetes
County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years:
United States 2006
Percent
www.cdc.gov/diabetes
County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years:
United States 2007
Percent
www.cdc.gov/diabetes
County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years:
United States 2008
Percent
www.cdc.gov/diabetes
Diabetes Type II
• In 2011: 25.8 million children and adults had diabetes ( 8.3%)
• Diagnosed: 18.8 million
• Undiagnosed: 7.0 million
• Pre-diabetes: 79 million!
• New cases: 1.9 million new cases in 2010
• Age 20 or older - 11.3%
• Age 65 or older- 26.9%
Diabetes- complication statistics
• Diabetics have 2-4 times the incidence of heart disease
• Diabetics have 2-4 times the incidence of stroke
• Diabetes is the leading cause of blindness
• Two-thirds of diabetics also have hypertension
• Diabetes is the leading cause of kidney failure
• Leading cause of non-traumatic limb amputations
Causes of Surprises
• Newly found diabetes
• Many undiagnosed diabetics discovered on insurance testing
• Newly found Hepatitis
• Six kinds of viral hepatitis: A,B,C etc
• Hepatitis A: food borne, usually short illness, self limited
• Hepatitis B & C are public health concerns
Hepatitis B
• Endemic in many parts of the world e.g. SE Asia, China, India, Africa
• Vaccination is available and routine in most countries
• Most frequent cause of chronic active hepatitis (CAH)
• CAH is the leading cause of hepatic carcinoma and cirrhosis
• Diagnosis requires blood testing and many times liver biopsy
• Treatment is available, response is variable
• Pre-Core mutant is particularly dangerous
Hepatitis C
• Used to be called non-A, non-B hepatitis
• Three strains (1,2,3) with strain one being the most pathologic and most
common
• It’s symptoms can remain hidden for decades
• Many exposures occurred prior to testing especially blood products
• Since testing blood, most exposures are related to IV drug use or sexual
contact
• 75% of HCV are unaware they are infected
Hepatitis C
• Feb 21, 2012 CDC study showed:
• 3.2 million Americans infected, 170 million worldwide, most- undiagnosed
• 1 in 33 baby boomers (born 1945-1965) are infected
• in 2007 it surpassed HIV in number of deaths
• “It is a silent epidemic” Dr John Ward, CDC hepatitis chief
• Treatment is similar to Hepatitis B with interferon and anti-virals
• Liver biopsy is essential to determine severity of disease; the extent of disease
is not proportional to liver enzymes
• 40% of incarcerated inmates are Hep C positive
• It is a leading cause of liver failure, cirrhosis, and liver cancer
• Hepatitis C is the leading cause for liver transplantation in the US
The famous with Hepatitis C
What information is useful for underwriting
hepatitis
• Is this a new finding or well studied?
• What studies have been done?
• Serology, viral loads, what strain?
• How long ago?
• liver biopsy - gold standard to establish degree of damage
• Treatment given
• The more information the better, underwriters typically do not assume the best
case scenario
Surprises: Elevated liver enzymes
• Diverse etiologies
• Obesity - steatohepatitis
• Alcohol
• NSAIDs
• Gallbladder disease
• Hepatitis- infectious and non-infectious
• Toxins
Elevated liver enzymes
• Wilson’s disease - copper storage disease
• Hemochromatosis - iron overload
• Drugs- especially anti-seizure medications
• Acute illnesses
• Tumors
• Pancreatic Disease
Surprises: HIV
• See an occasional unexpected result
• Many positive tests are never requested by applicant - “likely knew”
Electrocardiograms
• For many, the insurance examination EKG is their first
• Many electrical changes that occur in the heart (and on the EKG) have no
symptoms
• Many times the doctor does not discuss EKG findings with their patient
• Obtaining a good quality, properly run EKG in the field can be a challenge
Other reasons for Surprises
• Applicants don’t know what’s in their medical records
• For example: “Mr Smith tells me that he is only drinking two beers a week
but I find that very hard to believe. I estimate that he must be drinking at
least a six-pack every day”.
• Applicants don’t follow through with recommended tests:
• For example: “Bob’s chest pain has several elements that are very
worrisome for coronary artery disease. I have recommended that he
undergo a stress thallium treadmill.”
• Bob considered this a “suggestion that he could follow or not”. He elected
“not”.
Other reasons for Surprises
• Applicants hear a different story from their doctor
• Bob hears: “You are doing great, keep up the good work!”
• In reality: For an obese, hypertensive, diabetic who smokes and just had a
heart attack you are doing great.
• Wrong information in the chart
• Patients mislead themselves about the state of their health
Why do applicants hear a different story from
their personal doctor and insurance medical
director?
• Our “headlights” are set on different scales:
• The average physician’s field of vision is at greatest 5 years ahead
• The med director is projecting out perhaps many decades (age 85 or more)
and has “one bite at the apple”.
• Physician uses his experience and some clinical studies of limited duration
• Med Director uses actuarial data
Actuarial table- Male, (tobacco not considered)
AGE
Std
150%
200%
300%
500%
2
73
68
65
60
54
25
51
47
44
39
34
50
28
24
22
19
15
75
12
9
8
6
4
Why do applicants hear a different story from
their personal doctor and insurance medical
director?
• Our “headlights” are set on different scales:
• The average physician’s field of vision is at greatest 5 years ahead
• The med director is projecting out perhaps many decades (age 85 or more)
• Physician uses his experience and some clinical studies of limited duration
• Med Director uses actuarial data
• “Poker Chip Syndrome”
• Typical phone conversation
• Physician’s duty is to represent his patient and their best interests
Why do applicants hear a different story from
their personal doctor and insurance medical
director?
• Survey published February 2012 issue of Health Affairs
set off a round on controversy
• 1,891 physicians across the country
• Over fifty percent admitted describing a patient’s
prognosis in a way “they knew was too rosy”
• 20% said they hadn’t fully disclosed a medical mistake
for fear of being sued
• 1 in 10 admitted telling a patient something that wasn’t
true in the past year.
Popular Myths on Aging
• 100 year olds are growing rapidly
• In 1990: 37,306
• In 2000: 50,454
• In 2010: 71,991
• The two week challenge
• What is middle age
• at what age does the roller coaster cross the summit?
• Pro athletes and celebrities are great risks
• Money buys good health
• Money buys access to good health care
Why do different companies rate differently?
Why do different companies rate differently?
• Example:
• 45 year old man applies for $2.5 million in term life. He denies any
previous medical history but his cholesterol is modestly elevated and his
father died at age 55 from a heart attack. No medications. Slightly
hypertensive on exam and a bit overweight. He smokes.
• His electrocardiogram shows the following:
Normal Tracing
Applicant’s Tracing
Why do different companies rate differently?
• Example:
• 45 year old man applies for $2.5 million in term life. He denies any
previous medical history but his cholesterol is modestly elevated and his
father died at age 55 from a heart attack. No medications. Slightly
hypertensive on exam and a bit overweight. He smokes.
• His electrocardiogram shows the following:
• Based on his EKG we elected to make no offer but decided to send the
case to 3 reinsurers. Each Reinsurer got exactly the same information.
Reinsurers’ Responses
Reinsurer A
Reinsurer B
Decline
Table H
Reinsurer C
Standard
How to explain?
• different reinsurance reference
manuals
•Beauty is in
the eye of
the
beholder!!
Conclusions:
• We want to help you sell....If you don’t make money, we don’t make money!
• Our goal is to make your job and your client’s underwriting process as
convenient as possible but still gather the necessary information to underwrite
properly.
• Surprises do come up in the underwriting process mainly due to unanticipated
medical history and lab results
• Differences in underwriting offers can be hard to explain!
• On Your Side is not just a slogan for Nationwide
Questions?