wahlu critical underwriting issues betsy sears. examone, inc. copyright 2011, all rights reserved...

WAHLUCritical

Underwriting Issues

Betsy Sears

ExamOne, Inc. Copyright 2011, All Rights Reserved

Evolution of Underwriting

Earliest Mortality Tables Permit

Accurate Pricing by Age and Sex

1692 1948

Framingham Heart Study Begins

Quantification of Cardiovascular

Risk

1980s

HIV Testing Inaugurates Era of Routine Blood

Screening

Cotinine Testing Enables Credible

Non-Smoker Pools

Today

Risk IQ Offers Data

Analytics and Decision Support

Age and Sex Broadly Defined Risk Categories

Individualized Risk Assessments

2000s

Teleunderwriting, Prescription

History and Other Data Products Provide More

Detail

Confidential and Proprietary - Do not Copy or Distribute. Quest, Quest Diagnostics, ExamOne, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. All third party marks - ® and ™ - are the property of their respective owners. © 2011 Quest Diagnostics Incorporated. All rights reserved.


New Tests & Trends

A1c screening Risk IQOlder Age Testing


Diabetes

25.8 M diabetics in U.S. (9% of population)

18.8 M diagnosed 24% (7M) undiagnosed (50% 10 years ago)

1.9 M new cases 2010 79 M pre-diabetic 450,000 people die annually

http://www.cdc.gov/diabetes/faq/research.htm


CDC Number (in Millions) of Civilian, Noninstitutionalized Persons

with Diagnosed Diabetes, United States, 1980–2010

Centers for Disease Control and Prevention 2011


Developments in Hgb A1c American Diabetes Association: new

guidelines for diagnosing and treating diabetes January 2010

Big change: recommendation that A1c now be used to diagnose pre-diabetes and diabetes

Screen guidelines

Diabetes Care January 2010 33:S11-S61


Hgb A1c Glucose passes freely into and out of red

blood cells and reaches equilibrium

Glucose binds to hemoglobin

Hgb A1c gives picture of average serum glucose over previous 2 to 3 months (rbcs turn over every 120 days)

Not affected by glycolysis


Hgb A1c: Predicting Diabetic Risk

Prospective 3 year study - VAMC 1253 outpatients; age 45 – 64 4.5% (52) diabetes at baseline;

additional 73 by end of third year Baseline HbA1c and baseline body

mass index (BMI) were the only significant predictors of new onset diabetes Edelman, MK Olsen, TK Dudley, AC Harris, EZ

Journal of General Internal Medicine, 2004


EPIC-Norfolk Study A1c “In men and women A1c concentrations predicted coronary heart,

CV disease, and total mortality…independent of and only slightly attenuated after adjustment for known risk factors”


Hgb A1c

Guidelines suggest: A1c > 6.4% be used to diagnose diabetes (threshold for retinopathy)

Studies have shown: A1c 5.7 – 6.4% have an 88% chance of developing diabetes over next 6 years

Those with A1c > 6% should be considered at very high risk of subsequent diabetes


A1c Testing

The past: Reflex when serum glucose, urine

glucose, fructosamine are elevated or . . .

History of Diabetes

Current: Screening – Age 40 and up


ExamOne A1c Summary

Insurance pilot studies: 8-36% of those with: normal serum glucose, fructosamine, and

negative urine glucose have elevations of A1c 21 of top 25 volume companies are doing

some screening with A1c Through March 2012 (YTD) – 49% of all

ExamOne bloods had an A1c performed


A1c Summary A1c screening is viable option for identifying

undiagnosed diabetics A1c associated with CV events & death We are missing significant numbers of

elevations using current reflex criteria

Glucose < 60 29% A1c > 6.1 Glucose 60 – 109 31% A1c > 6.1

Antiselection?


What If You Could…

Reduce underwriting requirements such as APS

Reduce claims More accurately assess risk Underwrite with more confidence


ExamOne, Inc. Copyright 2011, All Rights Reserved Confidential – Do not copy or distribute | 17

Risk IQ: What is it?Data analysis tool to help u/w gauge mortality riskMillions of applicant lives from 2001 to todaySS death master file utilized with results to analyze

>144 variables: Multivariate analysisPercentile ranking of the mortality risk associated

with an applicant’s specific laboratory and physical measurement profile

Each applicant is ranked relative to his or her peers–Members of the same age and gender group

Mortality runs from less than half that expected for low Risk IQs to more than 10x for Risk IQs of 99

0 99


Contributors to Increased Risk45-Year-Old MaleNon-Smokers

63-Year-Old MaleNon-Smokers

Confidential and Proprietary - Do not Copy or Distribute.

Risk IQ Hazard by Cause of Death

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All Dea

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All Cla

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Heart D

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All Applicants



LABORATORY TESTINGfor the “mature” age group


What is “old?”

1936 - life expectancy was 61; Social Security Administration used age 65

2008 - average life expectancy is 78.7 years

Calendar vs. biological

www.cdc.gov


Feisty vs. Frail

There can be a big difference in health and expected mortality between two elderly individuals that are the same age


What starts the downhill trend?

Atherosclerosis Anemia Obesity Cardiovascular disease Chronic renal insufficiency Depression Cognitive impairment


Laboratory tests – older age Microalbumin Serum creatinine Serum albumin and cholesterol Hemoglobin NT-proBNP Cystatin C


Hemoglobin

The iron-containing oxygen-transport protein in the red blood cells

Hemoglobin transports oxygen from the lungs to the rest of the body, such as to the muscles, where it releases the oxygen for cell use

Purple top - stability


Prevalence of Anemia


AnemiaCauses of anemia Chronic disease Iron deficiency

– Renal insufficiency – Cancer– Inflammatory disorders– Chronic infections– Acute, chronic hepatitis– Myelodysplastic syndrome– Medication, alcohol – Nutritional deficiency

2x risk of physical decline

National Health And Nutrition Examination Survey 2009 (NHANES)


Anemia

Consequences of anemia in elderly Diminished cognitive function Increased frailty Poor exercise performance Risk of developing dementia Decreased mobility Increased risk of recurrent falls Lower bone density and skeletal muscle density Increased risk of depression Elevated risk of hospitalization and of complications

during hospitalization


Hemoglobin Study in Elderly

Compared association of Hgb concentration and anemia status with subsequent death over time in elderly

5,888 individuals age 65 and up 1989 - 1993 After 11.2 years of follow-up, lower hemoglobin

concentrations were associated with increased mortality risk, independent of many potentially confounding factors

Arch Intern Med. 2005; 165: 2214-2220

ExamOne, Inc. Copyright 2011, All Rights ReservedCopyright restrictions may apply.

Zakai, N. A. et al. Arch Intern Med 2005;165:2214-2220.

Kaplan-Meier curve of survival over 11.2 years by anemia status (based on World Health Organization criteria)


Anemia in the Elderly

Extremely common problem: associated with increased mortality and poorer health-related quality of life, regardless of underlying cause of low hemoglobin 2007 - 36M age > 65

2050 - 85M age > 65


Heart Disease - NT-proBNP 5.3 million afflicted CHF in U.S. ($40 billion) Each year, another 550,000 people

diagnosed for the first time Hospital discharges for HF rose from 400,000

in 1979 to 1,084,000 in 2005; increase of 171 percent (NHDS and NHLBI; AHA computation)

People age 40 and > have a 1 in 5 chance of developing CHF in their lifetime;


Congestive Heart Failure


Congestive Heart Failure

CHF and Underwriting Symptoms Nonspecific– Shortness of breath– Swollen feet and ankles

But echocardiograms too expensive and inconvenient to use routinely

Clinical CHF – 50% or > mortality at 5 yrs


Natriuretic Peptides NT-proBNP

Regulate homeostasis of salt and water Cardiac ventricles: ProBNP BNP NT-proBNP

Dilates blood vessels – reduces fluid load and pressure on heart

Elevated by increased Ventricular tension, CAD, Atrial Fibrillation

More stable than BNP


NT-proBNP - Mortality studies

Kragelund Study 1034 patients –stable angina and angiographically-

confirmed disease 9 year follow-up – 288 deaths (28%) Significantly lower NT-proBNP levels in survivors Independent of hypertension, smoking, high

cholesterol By adding NT-proBNP – enhance capacity to identify

high risk individuals Normal NT-proBNP values rule out CV disease

Kragelund, C. et al. N Engl J Med 2005;352:666-675


Overall survival among patients with stable coronary artery disease with progressive mortality associated with increasing levels of NT-pro-BNP


NT-proBNP – Mortality studies

Rancho Bernardo Study 957 persons, mean age 77, followed for

nearly 7 years Subset free of CV disease; elevated

NT-proBNP; mortality 3.5 fold increase NT-proBNP turned out to be a superior mortality

marker than troponin T, smoking, diabetes, fasting blood sugar and all lipid parameters

Journal of the American College of Cardiology. 52(2008):450


NT-proBNP – Mortality StudyCV Risk Study in Elderly 2975 community dwelling older adults free of HF NT-proBNP measured baseline – then 2 to 3 years

Results: NT-proBNP levels in highest quintiles (267.7pg/ml)

independently associated with greater risks of HF Inflection point of elevated risk: NT-proBNP 190 pg/ml

Conclusions: NT-proBNP levels independently predict heart failure and cardiovascular death in older adults. NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk

J Am Coll Cardiol, 2010; 55:441-450


NT-proBNP According to the Journal of the American Medical

Association “elevated levels of NT-ProBNP predict cardiovascular morbidity and mortality, independent of other prognostic markers, and identify at risk individuals even in the absence of systolic or diastolic dysfunction by echocardiography”

ExamOne – 15 out of 20 largest clients

screening 125 pg/ml < age 75 - 17% elevated 450 pg/ml age 75 or older - 14% elevated

JAMA. 2007;297(2):169


OLDER AGE TESTING NT-proBNP

Consider screening for age > 60 and higher face amounts

Order for shortness of breath, swelling of feet and legs

Order for known or suspected Coronary Disease

Excellent marker for

preferred risk for elderly


Kidney Disease - ESRD Prevalence (2004): 472,099 U.S. residents

were under treatment as of the end of the calendar year.

Resulting from these primary diseases: Diabetes: 172,938 Hypertension: 114,481 Glomerulonephritis: 77,121 Cystic kidney: 21,397 All other: 86,162

Incidence (2004): 104,364 U.S. residents were new beneficiaries of treatment


Kidney Disease - ESRD


OLDER AGE TESTING

Creatinine levels underestimate reduction of kidney function in the elderly– Not sensitive to small changes– Less muscle mass, less creatine and its

metabolite creatinine


Cystatin C – What is it?

Protease inhibitor produced by nearly all human cells; filtered by the glomerulus

Reabsorbed; broken down by the renal tubule Should remain at steady level in blood Independent of age, gender, race or lean

muscle mass Superior to serum creatinine/GFR Indicator of risk of heart failure

and death


Cystatin C – Morality Study

Analysis of 4637 participants aged 65 or older at inception

Followed for median 7.4 years Population was divided into Fifths (Quintiles)

based on laboratory results Compare Cystatin C, creatinine and GFR as

predictors for mortality Cystatin C – stronger predictor of death and

risk of CV events

NEJM 2005;352:2049-60


Mortality from All Causes According to Quintile of Measures of Renal Function Cystatin C categories – nearly linearly associated with risk of death


Resources

Ahmed N, et al. Am J Med 2007;120, 748-753. Frailty: An emerging geriatric syndrome

Arch Intern Med. 2005; 165: 2214-2220

Torpy, Janet M, MD, et al. JAMA, November 8, 2006 – Vol 296, No. 18 McQueen, M.P. Wall Street Journal, March 6, 2007 – D1 Life Insurers

Expand Offerings for the Elderly Archives of Internal Medicine. Monday 14th November, 2005 AHA at http://www.americanheart.org Mayo Clin Proc. 2007;82(8):958-966 Manini TM, Everhart JE, Patel KV, et al. JAMA 2006;296:171-179 Weber M, Dill T, Arnold R, et al. Am Heart J 2004;148:612-620 NEJM 2005;352:2049-60 Kragelund, C. et al. N Engl J Med 2005;352:666-675 Izaks, G. J. et al. JAMA 1999;281:1714-1717 Am Fam Physician 2000;62:1565-72

http://www.americanheart.org/


The end! Thank you for your attention

[email protected] 913-577-1306

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wahlu critical underwriting issues betsy sears. examone, inc. copyright 2011, all rights reserved...

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diagnosed diabetes

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