Nature of the information and type of medical examinations carried out "Predictivity, Genetic Testing and Insurance“ Strasbourg 3-4 December2007 António Maia Gonçalves, MD. Portugal

Nature of the information and type of medical examinations carried out At the beginning of the 20th century, life expectancy at birth was 47.3 years. Today, the average life expectancy at birth is nearly 77 years. Life Expectancy at Birth Source: U.S. Department of Commerce, Bureau of the Census.

Nature of the information and type of medical examinations carried out Leading Causes of Death, 1900 Leading Causes of Death, 1997 Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System and unpublished data. 1997

Nature of the information and type of medical examinations carried out Individual behaviors and environmental factors are responsible for about 70 percent of all premature deaths in the United States Source:

Nature of the information and type of medical examinations carried out Uncertainty and risk are central issues in relation to health and health care services Healthy individuals do not necessarily fall ill, despite the presence of risk factors. Applying general and statistical knowledge to individuals is difficult either on epidemiological or epistemological grounds. Scientific knowledge and technological capabilities improve exponentially

Nature of the information and type of medical examinations carried out Health status, health risk and life expectancy of the applicant? Evaluation of health status and risk of developing disease of an applicant is commonly referred to as underwriting The goal of the underwriter is to determine whether and on what basis insurance can be issued as standard rates, offered at higher premium rates or with other limitations

Nature of the information and type of medical examinations carried out First is the health history: - history of past illness or accident (severity, degree of impairment, recurrence, future complications) - chronic conditions - family health information

Nature of the information and type of medical examinations carried out Secondly - current physical condition evaluation : - tests used by insurers are commonly used by clinicians - there are diagnostic and predictive tests - non-medical tests to detect behaviours associated with disability or disease. - blood biochemical profiles and urinalyses

Nature of the information and type of medical examinations carried out blood itself (e.g. anaemia), renal function, liver tests, cholesterol and triglycerides, immune disorders and viral infections (HIV, HBV and HCV). screen for evidence of use of specific prescription drugs, for drugs of abuse, and nicotine. APS (Attending Physician Statements)

Nature of the information and type of medical examinations carried out Ability of these tests to correctly identify medical conditions? -75% of applicants are healthy -Sensitivity of each test -Erroneous judgement lead to more exams

Nature of the information and type of medical examinations carried out Common cancer screening tests asked by underwriters: -Stool occult blood tests -Mammography -PSA (prostatic specific antigen) -PAP test (papanicolaou smear) -Chest x-ray or CT scan

Nature of the information and type of medical examinations carried out Lung cancer: - kills approximately 90% of the 1.2 million people diagnosed annually worldwide -There aren’t any exams effective as a screening methodology -Modern screening trials use spiral computed tomography (CT) -High number of benign lesions detected

Nature of the information and type of medical examinations carried out Prostate Cancer: -Prostate cancer remains the most commonly diagnosed solid tumor in men -no conclusive body of medical literature indicates that screening for this disease alters outcome -Digital rectal examination (DRE) -Serum prostate-specific antigen (PSA) testing

Nature of the information and type of medical examinations carried out Colorectal cancer: -Colorectal cancer is the third most common cancer in both men and women. In Faecal occult blood testing -Colonoscopy -Clinical practice guidelines strongly recommend colorectal screening for patients over 50 years old, but usually do not make recommendations as to the best method.

Nature of the information and type of medical examinations carried out Breast cancer: - breast self-examination (BSE) - clinical breast examination (CBE) - mammography - Mammographyc screening between the ages reduces mortality from malignancy

Nature of the information and type of medical examinations carried out Testing for heart disease -The prevalence of CHD (coronary heart disease) among those between the ages of is estimated at 0.7% for males, and 0.3% for females. -Approximately 13% of Acute Myocardial Events occur among males of this age.

Nature of the information and type of medical examinations carried out Testing for heart disease -CHD specific mortality has declined in the last 25 years by about 40%. -usual screening tests for CHD are EKG (electrocardiogram) and Exercise Stress Testing -risk factors identification including smoking habits, diabetes, elevated serum cholesterol and hypertension

Nature of the information and type of medical examinations carried out Testing for heart disease - WHO European Health Report 2005 points out that the burden of mortality and DALYs (Disability Adjusted Life Years) for the seven leading conditions can be attributed to just seven leading risk factors

Nature of the information and type of medical examinations carried out WHO European Health Report Coronary heart disease (CHD) -unipolar depressive disorders -cerebrovascular disease -alcohol use disorders -chronic pulmonary disease -lung cancer -road-traffic injury

Nature of the information and type of medical examinations carried out WHO European Health Report tobacco - alcohol -high blood pressure -high cholesterol -overweight -low fruit and vegetable intake -physical inactivity

Nature of the information and type of medical examinations carried out Hypertension is the top-ranking risk factor in the European region in terms of attributable DALYs (12.8% of total DALYs) and continues to be the most common risk factor for cardiovascular morbidity. Insurance market consider it a “rate up” condition

Nature of the information and type of medical examinations carried out Hypercholesterolemia is a major risk factor for development of CHD Is the most "decorated" molecule in history, having contributed to as many as 13 Nobel prizes Underwriters consider it a “rate up” condition HDL-cholesterol level is not considered on underwriter’s evaluation as a protective factor

Nature of the information and type of medical examinations carried out Diabetes have a higher prevalence of CHD Diabetes doubled the age-adjusted risk for cardiovascular disease in men and tripled it in women Risk factor modification by therapeutic lifestyle changes (TLC) as well as drug therapies can decrease morbidity and mortality in such patients Some insurance companies consider diabetes an insurable condition

Nature of the information and type of medical examinations carried out Testing for alcoholism - Health consequences of alcoholism -There are no definitive laboratory tests to diagnostic -Carbohydrate-deficient transferrin (CDT) -MAST (Michigan Alcohol Screening Test) -Underwriters usually consider it a “rate up” condition, but some consider it an uninsurable disease

Nature of the information and type of medical examinations carried out Underwriter judgment -Insurable -Unsurable -Exclusion waver -Higher premium

Nature of the information and type of medical examinations carried out Conclusions: - In the actual “state of the art” in Medicine insurers collect more clinical data than they need to evaluate current and future health of the applicant

Nature of the information and type of medical examinations carried out Conclusions: - Many tests and exams are asked in a blindfold way despite of the clinical context of the patient, and ignoring limitations of the exam itself.

Nature of the information and type of medical examinations carried out Conclusions: -Ethical issues raised are those concerned with protecting individual privacy and confidentiality -The question of what uses of a patient’s data are permissible is not exclusively a question of privacy but also of autonomy -APS and doctor-patient relationship

Nature of the information and type of medical examinations carried out Conclusions: - Underwriter criteria for risk classification (higher premium, exclusion waver, uninsurable) should be reviewed.

Nature of the information and type of medical examinations carried out Conclusions: -Only when the prognostic value of a test, or of a clinical entity are clearly established in clinical practice, should that knowledge be used by Insurance Medicine