EUROPEAN PAPERS ON THE NEW WELFARE

Clinical Aspects of Long-Term Risk Management

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This part of our publication presents texts which are not original. They are motivated and written under various contexts: they provide an insight on the fact that the lenghtening of the life cycle is of greater and greater concern and interest in many different directions. The counter-ageing society is an issue which needs to be perceived on the basis of a true, practical as well as theoretical, multidisciplinary approach. On the basis of this larger vision, the work, activity and research of any specialist can be better appreciated and given value within the framework of a global background of reference.

1. Developing a Shared Language

The relationship between life/health underwriting and the medical profession may seem at first sight to be a simple one. However there is a complex dynamic between the two that is at its most intricate in the assessment of Long-Term Care (LTC) risk. Most of the difficulties arise in the way that the different professions know things and the need for one to adapt this knowledge to the paradigms of the other.
Medical knowledge and insurance knowledge are constructed differently. The questions asked by the insurance industry (often very obvious and straight forward) are not the questions that clinical researchers have set out to answer. Translating the knowledge is the challenge.
Developing a shared language between underwriter and physician is at the heart of growing the expertise to manage LTC risk. For the physician, this means an understanding of the product, the claims triggers, the way information is collected and presented, the risk and the processes of underwriting and claims. For the underwriter, developing an understanding of the clinical process of history-taking, examination, investigation, diagnosis treatment and management is the challenge. Whilst this is true for all life health underwriting, LTC brings its own particular issues.
Caring for elderly patients employs different ways of thinking about problems than caring for younger people. There is a greater interest in the person as whole. It is rarely enough to know that the person has chest pain after walking 100 meters and cannot get up stairs without getting breathless. This will probably be enough information for a doctor to order an echocardiogram and treat the results. Physicians looking after older people will want to know more about the person themselves and the problems that they are having with their day-to-day life.
They will want to understand the resources, both physical and psychological, that their patient has to manage the disease, and they will want to understand the impact of the problem on carers.

2. Bio-psycho-social Model

The theoretical model that underlies this thinking is the Bio-Psycho-Social model. It is not enough to know the diagnosis and severity of an illness to understand the impact that it has on a person. An arthritic knee for a person who has a desk job means that the commute to work is a bit uncomfortable; for an international fast bowler it may represent the end of a career, financial hardship and even depression. In order to measure the impact of a disease on a person’s function, a lot more has to be known about that individual.

Figure 1: The bio-psycho-social model

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Understanding the different impact these different psychological, biological and social factors present in a given individual is an important part of managing the risk.

3. Functional Changes

Activities of Daily Living (ADL) are the currency of functional change. Relatively little is known at the population levels about the level of ADL failure and how it is distributed, beyond a crude association with age. Relatively little is known about the progression of ADL failure at a population level. Different studies use different definitions or range of ADLs (Rickayzen and Walsh, 2002). Studies use different definitions of impairment or disability, and so their relevance to a particular LTC product and its claims triggers has to be teased out carefully.
Much is understood about the functional impairment in individual conditions (e.g., stroke), but older adults usually have more than one condition. For younger adults without medical problems, it remains very difficult to predict the likelihood of later ADL failure.
Several important principles can be drawn from the data.
1.    Young people with ADL failure are usually stable and tend to have relatively normal life expectancies. This is because the commonest cause of problems is trauma rather than degenerative disease. There are exceptions (e.g., Multiple Sclerosis) that would need to be examined on their own terms.
2.    In the ‘young old’ or lives under age 70, ADL failure is relatively short lived as it is often the result of a single catastrophic event such as stroke, myocardial infarction or cancer. The nearer to age 60 that the person develops ADL failure, the shorter the claim is likely to be.
3.    The ‘old old’, or people over age 70, who develop ADL failure, are likely to remain in claim for a long period. They represent a survivor cohort whose problems are the result of multiple pathologies. None of these may be of great severity, but in combination cause significant functional decline. They are often ‘frail’, and it is the development of frailty that best predicts the need for LTC.

4. Frailty

Frailty is a complex concept that has been thought about in many different ways over the years. Most concepts of frailty share the idea that some bio-medical measure can predict physiological (functional) capacity. Hand grip or timed walking test (Klein et al. 2005) serve as proxy measures for the overall functioning of an individual. Other concepts of frailty stress the dependence upon others for the performance of day-to-day functioning, whilst more socially-based ideas stress the ability of the person to carry out their roles in life (father, mother, club chairman, etc.). Some include a psychological component with cognitive impairment or depression as important factors. The majority seek to represent frailty as a continuum (how frail is this person?), but a smaller number of others treat it as a dichotomy (frail or not?) (Markle-Reid and Browne, 2003).

5. ‘Good for their Age’ — Stereotypes of Ageing

The question then arises: Is this person frail, ‘good for their age’ or a poor LTC risk?
Stereotypes of ageing are difficult to displace from the underwriting process. What do you expect at 72? If the underwriter uses their day-to-day experience of the elderly as a guide, then problems may ensue. Having a relative who developed dementia in their early 60s may well colour their judgement compared to one who has experienced grandparents as active and engaged with the world. Merely being ‘good for their age’ is not a basis for an underwriting decision.
The challenge for the underwriter becomes taking a hard look at the evidence that is available to them, putting aside the stereotypical pictures of ageing and attempting to identify applicants with a degree of frailty that makes them an unacceptable LTC risk.

Christopher Ball (MRCPsych) is a consultant psychiatrist with the South London and Maudsley NHS Trust and a consulting medical officer for Gen Re LifeHealth in the UK. He was appointed to a Consultant’s post in 1993 and since 1995 has worked on a wide range of insurance and reinsurance related projects. He has written extensively on psychiatric issues both in mainstream medical academic press and for the insurance industry.


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