A LTCI Approach to Managing Rheumatoid Arthritis

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1 A LTCI Approach to Managing Rheumatoid Arthritis A bit of Science, a bit of Art, a lot of Perseverance... Stephen K. Holland, MD Senior Vice President & Medical Director Long Term Care Group, Inc. Long Term Care International Forum April 2006, Las Vegas, NV

2 Rheumatoid Arthritis A chronic, systemic, inflammatory autoimmune disease Primarily inflammation of the synovium Long-term joint damage, resulting in Chronic pain, Loss of function Disability Systemic: lung, pericardium, nodules, bone marrow, vasculitis,, etc. Cause unknown

3 Epidemiology Rheumatoid Arthritis Effects approx 2.5 million in US (1-1.5% of population) Prevalence increases with age (can affect all ages) Peak incidence between the 4 th -6 th decades More than 2.5 times higher in women than in men Genetic basis 15-30% concordance in monozygotic twins A relative risk of 3.5 for RA in monozygotic versus dizygotic twins

4 Permanent joint damage Joint deformities Loss of function Rheumatoid Arthritis Mortality rates 2x greater than general population A major cause of morbidity and dependency Medical costs and indirect expenses due to lost wages >$3 billion annually (estimated) Less than 50% of working age adults with RA are still employed 10 years after disease onset

5 Normal Joint

6 The Joint in Rheumatoid Arthritis In RA, inflammation accompanies thickening of the synovial membrane, causing the whole joint to appear swollen because of swelling in the joint capsule. The inflamed joint lining enters and damages bone and cartilage, and inflammatory cells release an enzyme that gradually digests bone and cartilage. Space between joints diminishes, and the joint loses shape and alignment. (Source: Olsen, FDA.) N. J. et al. N Engl J Med 2004;350:

7 Arthritic Joints

8 Rheumatoid Arthritis Inflammation in Rheumatoid Arthritis Inciting antigen is unknown Antigen drives lymphocyte proliferation Production of rheumatoid-factor antibody Complement fixation amplifies destructive cascade Attracting additional inflammatory cells Increased production of cytokines and enzymes Mediate tissue damage (cartilage loss & bone erosion)

9 Rheumatoid Arthritis Progresses in three stages. Stage I: swelling of the synovial lining, causing pain, warmth, stiffness, redness and swelling around the joint Stage II: rapid division and growth of cells, or pannus, which causes the synovium to thicken Stage III: inflamed cells release enzymes that may digest bone and cartilage, often causing the involved joint to lose its shape and alignment, more pain, and loss of movement

10 A 38-year year-old woman with a five-year history of rheumatoid arthritis Ikari, K. et al. N Engl J Med 2005;353:e13

11 Rheumatoid Arthritis Differential Diagnosis Polymyalgia Rheumatica (PMR) Calcium Pyrophosphate Deposition Disease (CPPD) Gouty arthritis Osteoarthritis (OA) Occult malignancy and thyroid disease (rare)

12 Early Diagnosis and Treatment Diagnosis made by 7 diagnostic criteria Clinical - morning stiffness, arthritis of three or more joints, arthritis of hands, symmetrical arthritis, rheumatoid nodules Lab - elevated serum rheumatoid factor, radiological confirmation At least 4 criteria present for a minimum of 6 weeks

13 Early Diagnosis and Treatment More than 30% have radiologic evidence of joint erosion at presentation More than 60% will have joint erosion within 24 months Critical to start therapy within 3 months of diagnosis

14 Early Diagnosis and Treatment Therapeutic success assessed by Joint tenderness and swelling Inflammatory markers Erythrocyte sedimentation rate C-reactive protein Patient s own assessment of pain, disease activity and physical function

15 Rheumatoid Arthritis - Treatment Nonsteroidal anti-inflammatory inflammatory drugs (NSAIDs) Corticosteroids Disease-modifying anti-rheumatic drugs (DMARDs) Synthetic Biologic Joint replacement and repair Physical and Occupational Therapy

16 Rheumatoid Arthritis - Treatment NSAIDs and Cox-2 2 inhibitors Relieve pain and stiffness Do not slow progression of disease Increased GI complications (1.5% hospitalized with GI probs) No therapeutic benefit of Cox-2 2 over NSAIDs Corticosteroids Potent suppressors of inflammation Dose dependent side-effects effects (cataracts, osteoporosis, HTN, lipids) Ample data establishing that disease progression is slowed

17 Disease-Modifying Anti-Rheumatic Drugs Goal Sustained Suppression of Inflammation Old School Anti-malarials Penicillamine Oral gold In vogue Methotrexate - antimetabolite also sulfasalazine and IM gold

18 Disease-Modifying Anti-Rheumatic Drugs Sustained Suppression of Inflammation New School Tissue Necrosis Factor-α inhibitors Infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira) New, New School Interleukin-1 blocking agent - Anakinra (Kineret) Pyrimidine synthesis inhibitor - Leflunomide (Arava)

19 Inflammation in the Rheumatoid Joint Olsen, N. J. et al. N Engl J Med 2004;350:

20 Responses to Drug Therapy in Seven Studies Involving Patients Receiving Methotrexate O'Dell, J. R. N Engl J Med 2004;350:

21 A 38-year year-old woman with a five-year history of Rheumatoid Arthritis Prior to Therapy After 17 months of Methotrexate Ikari, K. et al. N Engl J Med 2005;353:e13

22 Disease-Modifying Anti-Rheumatic Drugs TNF-α inhibitors & Interluekin-1 Blocking Agents Indicated for RA refractory to methotrexate Expensive Parenteral injection site reactions, infusion reactions Complications infections, cancer, vasculitis, MS-like disorder Very little long-term data Are remissions durable? Unknown long term sequelae of potent immunosuppressive Rx

23 Rheumatoid Arthritis The Challenge: Underwriting RA Long Term Care International Forum April 2006, Las Vegas, NV

24 RA Underwriting Considerations Risk Assessment Disease activity Joint inflammation Pain Stiffness Bio markers Systemic involvement Stability of Rx Types of Rx TNIF Inhibitors Corticosteroids, PT/OT Analgesic use Narcotics, Pain Clinic Functional Impact Co-Morbidity Consideration Build/BMI Osteoporosis Gait and transfers Falls and fractures Cardiovascular Disease Peripheral vascular disease Renal disease Complications of therapy Smoking Daily activities

25 LTCG Underwriting Experience with RA Average at underwriting: 63.9 years 76.3% female 48.3% less than 65 years of age Underwriting Stats 50.7% approved 49.3% declined Underwriting Stats 1.2% of applicants have RA 0.8% of active insureds have RA

26 Rheumatoid Arthritis The Reality: Managing RA Claims Long Term Care International Forum April 2006, Las Vegas, NV

27 Claims Experience LTCG Database - Claims Expenditures to Date More than $242 million claims expenditures LTCG has approved and paid 5,665 LTCI Claims 43.7% Open (2,475 open claims) 56.3% Closed (3,190 closed claims) Average age of claimant: 77.5 years Gender: 67.7% female, 32.3% male Almost 20% less than 65 years of age 23% living alone at time of claim LTCG Claims and Underwriting Database 12/2005

28 Characteristics of Claimants with RA Average at Claim: 77.5 years 64% female, 36% male Average duration to claim: 66.7 months 19.7% less than 65 years of age Insureds with RA have produced 85 claims 1.5% of all paid claims Insureds with RA have incurred $3,915, % of all claims payment LTCG Claims and Underwriting Database 12/2005

29 Rheumatoid Arthritis Claims Experience 133 Requests for Benefits 91% approved for benefits 9% did not qualify for benefits 121 Approved Claims 85 claims have incurred payments 36 have not incurred benefit payments 85 Paid Claims 40 claims remain open 45 claimants have recovered or died LTCG Claims and Underwriting Database 12/2005

30 Rheumatoid Arthritis Claims Experience 45 Paid claimants recovered or died 58% within 24 months 31% within months 11% >48 months 36 Approved but no payments 19% in deductible 81% recovered prior to payment LTCG Claims and Underwriting Database 12/2005

31 Rheumatoid Arthritis Claims Experience Top 5 reasons for claim Complications, limitations of arthritis 29.7% Dementia 21.6% Stroke 10.1% Fractures, falls, injuries 7.8% Cancer 5% Overall duration of Care >20% longer than other claimants LTCG Claims and Underwriting Database 12/2005

32 Rheumatoid Arthritis: Location of Care Location of Care as of 12/31/2005 Hospice, Other 10% 12% Nursing Home 35% Independent Provider 18% Home Care Agency 25% ALF LTCG Claims and Underwriting Database 12/2005

33 Rheumatoid Arthritis: Location of Care Claimant s 65 years and younger Location of Care as of 12/31/2005 Independent Provider Hospice, Other 1% 47% 2% Nursing Home 15% ALF 25% Rapid migration to home setting Home Care Agency LTCG Claims and Underwriting Database 12/2005

34 Rheumatoid Arthritis: Claims Rates 6,000 Paid Claims Count of Paid Claims 5,000 4,000 3,000 2,000 1, ,665 1, Risk Pool RA OA LTCG Claims and Underwriting Database 12/2005

35 Rheumatoid Arthritis: Claims Rates Paid Claims/1000 Insured Lives Paid Claims per 1000 Insured Lives No Disease RA OA LTCG Claims and Underwriting Database 12/2005

36 Rheumatoid Arthritis: Claims Rates 70 Age Adjusted - Paid Claims/1000 Insured Lives Paid Claims per 1000 Insured Lives No Disease RA OA LTCG Claims and Underwriting Database 12/2005

37 Rheumatoid Arthritis: Claims Rates Age Adjusted - Paid Arthritis Claims/1000 Insured Lives Paid Arthritis Claims per 1000 Insured Lives No Disease RA OA LTCG Claims and Underwriting Database 12/2005

38 Rheumatoid Arthritis Claims Experience Claims Expenditures to Date Total $242 million claims expenditures RA on application: $3.9 million (1.6%) OA on application: $84 million (35%) LTCG Claims and Underwriting Database 12/2005

39 Rheumatoid Arthritis: Loss Ratio All Ages: Claims Payment/Premium Collected Loss Ratio No Disease RA OA LTCG Claims and Underwriting Database 12/2005

40 Rheumatoid Arthritis: Loss Ratio Ages Years: Claims Payment/Premium Collected Loss Ratio No Disease RA OA LTCG Claims and Underwriting Database 12/2005

41 RA Insureds: : Other Claims Age Adjusted - Paid Claims/1000 Insured Lives Paid Claims per 1000 Insured Lives Paid Dementia Claims None RA OA None RA OA Paid Stroke Claims LTCG Claims and Underwriting Database 12/2005

42 Rheumatoid Arthritis: Lessons Learned RA will Continue to be a Challenge to Underwrite Important factors Extent and severity of disease - Disease activity - Stability of medical regimen, use of analgesics, etc. - Joint replacement - Extra-articular articular disease Co-morbidity BMI, infections, osteoporosis, CVD Impact of disease - current activities, IADL s, independence

43 Rheumatoid Arthritis: Lessons Learned A Frequent and Challenging Claim to Manage Young Claimants with end-stage disease Disease activity waxes and wanes Frequent monitoring necessary Significant potential for recovery Overwhelmingly home care is location of choice Independent Providers very popular Care Management essential

44 Rheumatoid Arthritis: Lessons Learned A Frequent and Challenging Claim to Manage Older Claimants with end-stage disease End-stage quiescent disease with functional deficits Dependency often precipitated by - Joint replacement - Falls, fractures - Deconditioning,, fatigue IADL s assist as important as ADL assist ALF very popular Potentially very long claims (though recovery occurs) Care Management essential

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