obesity trends* among u.s. adults brfss, 2006

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. AdultsBRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Prevalence of Type II Diabetes

www.cdc.gov/diabetes

County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2004

Percent


Percent


• 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 Type II

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

Decline

Reinsurer B

Table H

Reinsurer C

Standard

How to explain?• different reinsurance

reference manuals

•Beauty is in the eye of the beholder!!

• 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

Conclusions:

Questions?

obesity trends* among u.s. adults brfss, 2006

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