spinal disorders claims in long term care insurance · typical spinal disorder claim: 73 years of...

$: Spinal Disorders Claims in Long Term Care Insurance · Typical Spinal Disorder claim: 73 years of age, multiple spinal compression fractures 2+ ADL dependencies Home Health Care,$
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Spinal Disorders Claims inLong Term Care Insurance

It’s such a pain, why bother?

Stephen K. Holland, MDChief Medical Officer

Univita Health, Inc.Long Term Care International Forum, May 2011

Albuquerque, New Mexico

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

333

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, 2010

444

UnderstandingLTCI ClaimsExperience

Spinal Disorders

555

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

LTCI Claims Experience

Univita LTCI Underwriting and Claims Data Base 2011

666

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



777

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



888

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



999

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%



101010

Most frequent paid claimed events Mean

1. Pure Dementia $78,3152. Cancer $15,8743. Stroke $79,6794. Fractures/Injuries/Falls/Gait issues $56,5885. Arthritis &other Rheumatic diseases $67,8576. Parkinson’s disease $76,8307. Respiratory disease $38,8528. CHF, Cardiomyopathy $43,6589. Spinal disorders $69,53210.Diabetic complications $34,766



111111

Most frequent paid claimed events Mean Median

1. Pure Dementia $78,315 $54,8992. Cancer $15,874 $4,0243. Stroke $79,679 $51,8544. Fractures/Injuries/Falls/Gait issues $56,588 $26,4065. Arthritis &other Rheumatic diseases $67,857 $49,0506. Parkinson’s disease $76,830 $53,1197. Respiratory disease $38,852 $16,8668. CHF, Cardiomyopathy $43,658 $23,5759. Spinal disorders $69,532 $41,92110.Diabetic complications $34,766 $21,699



121212

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)



131313

0%

10%

20%

30%

40%

50%

60%

≤69 years 70-79 years ≥80 years

Spinal DisordersAll Others

Age DistributionSpinal Disorders versus All Other Diagnoses



141414

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Female Male


Gender DistributionSpinal Disorders versus All Other Diagnoses



151515

Home Health Care

62.4%

Assisted Living28.6%

Nursing Home8.9%

Spinal Disorders Location of Care



161616

0%

10%

20%

30%

40%

50%

60%

70%

Home Health ALF SNF

Spinal Disorders

All Others

Spinal Disorders versus All OtherLocation of Care



171717

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


DeceasedRecovered

70% ClosureRate

Spinal Disorders – Claim Closure



181818

0%

10%

20%

30%

40%

50%

60%

Recovered Deceased Exhausted


Claim ClosureSpinal Disorders versus All Other Diagnoses



191919

0%

10%

20%

30%

40%

50%

60%

70%

80%

Recovered Deceased Exhausted


Claim ClosureSpinal Disorders versus All Other Diagnoses



202020

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%



Age at RecoverySpinal Disorders versus All Other Diagnoses



212121

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%



Age at RecoverySpinal Disorders versus All Other Diagnoses



222222

0%

10%

20%

30%

40%

50%

60%

In Deductible ≤12 months 12-24 months


Timing of RecoverySpinal Disorders versus All Other Diagnoses



232323

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



242424

Spinal Disorder Claims in LTCI

Can LTCI Claims forSpinal Disorders be Managed?

252525

Benefit EligibleGrey Zone

Ineligiblefor Benefits

6/6 ADLDependencies

Coma

Three or More ADLDependencies

Severely Cognitively Impaired

Two ADL Dependencies;Cognitively Intact

Moderately Cognitively Impaired; ADL’s Intact

ADLIndependent

Mild Cognitive Impairment

The Spectrum of Benefit Eligibility

262626

The Spectrum of Benefit Eligibility

Benefit EligibleGrey Zone

Ineligiblefor Benefits

6/6 ADLDependencies

Three or More ADLDependencies

Two ADL Dependencies

ADLIndependent

SpinalDisorders

Careful Benefit EligibilityDetermination is Critical

Spinal Disorder Approval Rate: 72.4%

All Other Approval Rate: 89.1%

272727

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

282828

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

292929

LTCI Spinal Disorder Claims

Conclusions

303030

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

Conclusions

313131

Questionsand

Discussion

LTCIFAlbuquerque, NM

May 2011

spinal disorders claims in long term care insurance · typical spinal disorder claim: 73 years of...

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