Spinal Disorders Claims in Long Term Care Insurance

Transcription

1 Spinal Disorders Claims in Long Term Care Insurance It s such a pain, why bother? Stephen K. Holland, MD Chief Medical Officer Univita Health, Inc. Long Term Care International Forum, May 2011 Albuquerque, New Mexico 1

2 Agenda Amen to underwriting How common are LTCI claims for spinal disorders? LTCI claims experience Compression of morbidity and recovery Can we manage spinal disorder claims? Conclusions

3 Spinal Disorders and Disability UNUM Long Term Disability Claims 1. Cancer 12.1% 2. Complications of pregnancy 11.7% 3. Joint/muscle/connective tissue 10.1% 4. Back Injuries 8.1% 5. Cardiovascular disease 8.0% UNUM Corporate Disability Data Base,

4 Spinal Disorders Understanding LTCI Claims Experience 4

5 Carrier A - TQ Group LTCI policy 73% Comprehensive, 22% Facility only, 4% Partnership Active members: 156,104 Average age of active members: 69.3 years Gender: 60% Female, 40% Male Average policy duration: 10.7 years (max 17+ years) Total exposure: More than 24.2 million member months 5

6 Carrier A s Claims Experience 23,089 Requests for LTCI Benefits 17,927 Approved LTCI Claims 13,325 Paid LTCI Claims $810 million in Benefits Paid to Date Average Paid Claim: $60,796 Median Paid Claim: $37,376 Claim Closure - 3,961 Recoveries; 8,613 Deaths, 399 Exhausted Benefits 6

7 Risk Pool Disability profile 25% Cognitive Impairment (CI) 45% 2+ ADL deficits 30% Combined ADL & CI Setting of Care 48.8% Home Health Care 32.5% Assisted Living 18.5% Nursing Home 7

8 Most frequent paid claimed events * 1. Pure Dementia 24% 2. Cancer 14% 3. Stroke 11% 4. Fractures/Injuries/Falls/Gait issues 7% 5. Arthritis and other Rheumatic diseases 5% 6. Parkinson s disease 5% 7. Respiratory disease 4% 8. CHF, Cardiomyopathy 4% 9. Spinal disorders 4% 10.Diabetic complications 2% *Accounts for 80% of Paid Claims 8

9 As of 12/31/2010: 17,927 Approved; 13,325 Paid Claims 771 Spinal disorders claims Age at issue: 69.4 years Age at time of claims: 78.2 years $39,748,200 paid to date $51,554 average claim payment 17,146 Claims from all others Age at issue: 71.1 years Age at time of claims: 77.6 years $770,361,424 paid to date $45,082 average claim payment Spinal Disorders 4.3% Other than Spinal Disorders 95.7% 9

10 Most frequent paid claimed events Mean 1. Pure Dementia $78, Cancer $15, Stroke $79, Fractures/Injuries/Falls/Gait issues $56, Arthritis &other Rheumatic diseases $67, Parkinson s disease $76, Respiratory disease $38, CHF, Cardiomyopathy $43, Spinal disorders $69, Diabetic complications $34,766 10

11 Most frequent paid claimed events Mean Median 1. Pure Dementia $78,315 $54, Cancer $15,874 $4, Stroke $79,679 $51, Fractures/Injuries/Falls/Gait issues $56,588 $26, Arthritis &other Rheumatic diseases $67,857 $49, Parkinson s disease $76,830 $53, Respiratory disease $38,852 $16, CHF, Cardiomyopathy $43,658 $23, Spinal disorders $69,532 $41, Diabetic complications $34,766 $21,699 11

12 Typical Spinal Disorder Diagnoses Spinal compression fracture Osteoarthritis, degenerative disc disease (DDD) Spondylolisthesis, spinal stenosis Failed back surgery Spinal cord injury, traumatic vertebral fracture Ankylosing Spondylitis Radiculopathy Myelopathy Diffuse Idiopathic Skeletal Hyperostosis (DISH) 12

13 60% Age Distribution Spinal Disorders versus All Other Diagnoses 50% 40% 30% Spinal Disorders All Others 20% 10% 0% 69 years years 80 years 13

14 90% Gender Distribution Spinal Disorders versus All Other Diagnoses 80% 70% 60% Spinal Disorders All Others 50% 40% 30% 20% 10% 0% Female Male 14

15 Spinal Disorders Location of Care Assisted Living 28.6% Nursing Home 8.9% Home Health Care 62.4% 15

16 70% 60% 50% 40% Spinal Disorders versus All Other Location of Care Spinal Disorders All Others 30% 20% 10% 0% Home Health ALF SNF 16

17 100% Spinal Disorders Claim Closure 90% 80% 70% 70% Closure Rate 60% 50% 40% Deceased Recovered 30% 20% 10% 0% 69 years years 80 years 17

18 60% Claim Closure Spinal Disorders versus All Other Diagnoses 50% 40% Spinal Disorders All Others 30% 20% 10% 0% Recovered Deceased Exhausted 18

19 80% 70% 60% 50% Claim Closure Spinal Disorders versus All Other Diagnoses Spinal Disorders All Others 40% 30% 20% 10% 0% Recovered Deceased Exhausted 19

20 45% 40% 35% 30% Age at Recovery Spinal Disorders versus All Other Diagnoses Spinal Disorders All Others 25% 20% 15% 10% 5% 0% 69 years years 80 years 20

21 45% 40% 35% 30% Age at Recovery Spinal Disorders versus All Other Diagnoses Spinal Disorders All Others 25% 20% 15% 10% 5% 0% 69 years years 80 years 21

22 60% Timing of Recovery Spinal Disorders versus All Other Diagnoses 50% 40% Spinal Disorders All Others 30% 20% 10% 0% In Deductible 12 months months 22

23 Typical Spinal Disorder claim: 73 years of age, multiple spinal compression fractures 2+ ADL dependencies Home Health Care, 13 months, $41,921 paid Most costly claim to date: 64 years of age, spinal cord injury (quadriplegia) 5 ADL dependencies Assisted Living, 10.9 years, $666,347 23

24 Spinal Disorder Claims in LTCI Can LTCI Claims for Spinal Disorders be Managed? 24

25 The Spectrum of Benefit Eligibility Benefit Eligible Grey Zone Ineligible for Benefits 6/6 ADL Dependencies Coma Three or More ADL Dependencies Severely Cognitively Impaired Two ADL Dependencies; Cognitively Intact Moderately Cognitively Impaired; ADL s Intact ADL Independent Mild Cognitive Impairment 25

26 The Spectrum of Benefit Eligibility Benefit Eligible Grey Zone Ineligible for Benefits 6/6 ADL Dependencies Three or More ADL Dependencies Two ADL Dependencies ADL Independent Careful Benefit Eligibility Determination is Critical Spinal Disorder Approval Rate: 72.4% All Other Approval Rate: 89.1% Spinal Disorders 26

27 Active LTCI Claims Management Higher non-approval rates at claim submission Claimed event heavily biased towards IADL dependencies Significant early claims closure More than 56% of closed claims close via recovery More than 48% recover during deductible period An additional 51% recovery during the next 12 months There will be obstacles to recovery IADL abilities slow to recover; reinstatement of deductible Potential for fraud Symptoms are subjective LTC Insurance as a means of qualifying for SSI or DI Beware of requests for Independent Providers and informal care 27

28 Active LTCI Claims Management What Can We Learn from Acute Care Mechanical back pain rarely causes long term disability Pain and limitations from compression fractures are usually self limited Early mobilization and continued activities are critical Mode of therapy is less critical Active care management is effective Adequate analgesia Early mobilization Home Physical Therapy as bridge to outpatient therapy Coaching and self management 28

29 LTCI Spinal Disorder Claims Conclusions 29

30 Conclusions Spinal disorders are a fairly common LTCI claimed event Most claims for disorders of the spine are shorter than others Early intervention is important active claims management Many will recover during their deductible period A large number will recover during the first 12 months of claim Care Management can be very effective Encourage close medical follow-up Reach out to insured s PCP and care manager; coordinate efforts Encourage rehabilitation Recognize and focus on mitigating obstacles to recovery 30

31 Questions and Discussion LTCIF Albuquerque, NM May