Neurodegenerative Disorders Claims
in Long Term Care Insurance
Stephen K. Holland, MD
Chief Medical Officer, Univita Health
Long Term Care International Forum Annual Meeting
Miami, FL May 3, 2012
Agenda
 Amen to underwriting
 How common are LTCI claims for
neurodegenerative disorders?
 One Carrier’s LTCI claims experience
 Compression of morbidity and recovery
 Can we manage neurodegenerative disorder
claims ?
 Conclusions
Neurodegenerative Disorders and Disability
Long Term Disability Claims Survey 2010
Claim Diagnostic Category
2010 New Claims
2010 Existing Claim
Musculoskeletal
27.5%
30.1%
Cancer
14.6%
8.4%
Injuries and Poison
10.3%
7.8%
Cardiovascular
9.1%
12.7%
Mental Disorders
9.1%
7.7%
Nervous System
6.9%
13.4%
Pregnancy/Child Birth
5.1%
1.4%
Gastrointestinal
2.5%
2.2%
Respiratory
2.3%
3.0%
Council for Disability Awareness, 2011
LTCI Claims Experience
Typical Neurodegenerative Disorder Diagnoses
 Parkinson’s disease (PD)
 Essential Tremor
 Multiple Sclerosis (MS)
 Amyotrophic Lateral Sclerosis (ALS)
 Huntington’s Disease (HD)
 Progressive Supranuclear Palsy (PSP)
 Creutzfeldt-Jakob disease
 Other rare neurodegenerative diseases
Univita LTCI Underwriting and Claims Data Base 2012
Neurodegenerative Disorders
UNDERSTANDING
LTCI CLAIMS EXPERIENCE
Characteristics of Carrier A’s LTCI Claims
TQ Group LTCI policy





73% Comprehensive, 22% Facility only, 4% Partnership
Average age of active members: 56.3
Gender: 60.6% Female, 39.4% Male
Average policy duration: 12.8 years
Total exposure: 27,716,956 million member months
Claims Experience






25,152 Requests for LTCI Benefits
19,751 Approved LTCI Claims; 14,364 Paid LTCI Claims
$1.1 Billion in Benefits Paid to Date
Average Paid Claim: $63,532
14,513 Claims Closed
4,208 Recoveries (29%); 9,793 (67%) Deaths, 512 Exhaust Ben (4%)
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Risk Pool Disability Profile
 32% Cognitive Impairment (CI)
– 11% Cog Impairment only
– 21% Combined ADL deficits and CI
 67% 2+ ADL deficits without CI
Setting of Care
 50.7% Home Health Care
 32.5% Assisted Living
 16.8% Nursing Home
Overall Recovery Rate: 30%
Univita LTCI Underwriting and Claims Data Base 2012
Clinical Profile of All Paid LTCI Claimants
% Total Paid Claims
by Frequency
Disabling Condition
Pure Dementia
24.3%
Cancer
13.9%
Stroke
10.3%
Debilitating Fractures and Injuries
6.8%
Neurodegenerative Disorders
6.3%
Arthritis, Rheumatic Disease
4.6%
Respiratory Disease
4.0%
Cardiomyopathy, CHF
3.9%
Disorders of the Spine
2.5%
Dementia with falls, fractures or injury
2.0%
*Top ten conditions account for 79% of paid claims
Univita LTCI Underwriting and Claims Data Base 2012
Clinical Profile of All Paid LTCI Claimants
Total Paid Claims
% of Total Paid
Claims
Pure Dementia
$297,241,961
31%
Stroke
$126,832,831
13%
Neurodegenerative Disorders
$74,293,448
8%
Debilitating Fractures and Injuries
$60,361,987
6%
Arthritis, Rheumatic Disease
$48,899,817
5%
Cancer
$34,126,791
4%
Cardiomyopathy, CHF
$26,342,978
3%
Disorders of the Spine
$26,194,681
3%
Respiratory Diseases
$23,447,023
3%
Dementia - falls, fractures or injury
$22,934,826
2%
Disabling Condition
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
 As of 12/31/2011: 19,751 Approved; 14,876 Paid Claims
 932 Neurodegenerative disorders paid claims
– Age at issue: 69.7 years
– Age at time of claims: 75.0 years
Neurodegenerative
Disorders 7.9%
– $74,293,448 paid to date
– $79,714 average claim payment
 13,944 paid claims from all others
Other than Neurodegenerative
Disorders 92.1%
– Age at issue: 68.8 years
– Age at time of claims: 79.7 years
– $870,855,892 paid to date
– $65,532 average claim payment
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Most frequent paid claimed events Mean
 All LTCI Claimants
$63,532
Median
$35,030
 All Neurodegenerative Disorders
– Parkinson’s without Dementia
– Parkinson’s with Dementia
– ALS
– Severe Tremor
– Huntington’s Chorea
– Multiple Sclerosis
$50,061
$52,356
$59,678
$16,723
$42,303
$125,212
$91,220
$79,714
$77,691
$82,781
$31,106
$60,158
$156,884
$132,044
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Age Distribution
Neurodegenerative Disorders versus All Other Diagnoses
100%
90%
80%
70%
Parkinson's
Huntington's
ALS
MS
Tremor
All Other
60%
50%
40%
30%
20%
10%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Gender Distribution
Neurodegenerative Disorders versus All Other Diagnoses
90%
80%
70%
60%
50%
40%
30%
Male
Female
20%
10%
0%
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
All Neurodegenerative Disorders
Initial Location of Care
Nursing Home
16.2%
Home Health
55.5%
Assisted Living
28.3%
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Initial Setting of Care
Specific Neurodegenerative Disorders versus All Other
90%
80%
70%
60%
Parkinson's
Huntington's
ALS
Tremor
MS
All Other
50%
40%
30%
20%
10%
0%
Home Health
ALF
Nursing Home
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
All Neurodegenerative Disorders
Final Location of Care
Nursing Home
30.7%
Home Health
43.3%
Assisted Living
25.9%
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Typical Parkinson’s LTCI claim:




78 years of age, male, retiree
Parkinson’s for more than 10 year
3+ ADL dependencies
Home Health Care, 3.2 years, $81,469 paid
Most costly Parkinson’s LTCI claim to date:





87 years of age, female, spouse of retiree
Parkinson’s for more than 15 years
PD onset 3 years after issue, claimed 6 years after issue
5 ADL dependencies, demented, in nursing home
In claim 10.6 years, $675,309
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Typical Multiple Sclerosis LTCI claim:




59.5 years of age, female, active employee (MGI)
MS for more than 15 years
3+ ADL dependencies
Home Health Care, 3.2 years, $132,044 paid
Most costly MS LTCI claim to date:





68 years of age, male, active employee (MGI)
MS for more than 28 years
MS onset prior to application, claimed 4 years after issue
5 ADL dependencies, receiving care at home
In claim 10.7 years, $620,066
Univita LTCI Underwriting and Claims Data Base 2012
Life Expectancy
60
49
50
40
Parkinson's
General Population
38
31
30
21
20
9
10
5
0
25-39 years
40-64 years
65+ years
Age of Onset
Ishihara, J Neurol Neurosurg Psych 2007;78:1304-1309
Average Age at Death
Parkinson's
100
90
80
General Population
83
82
71
88
91
73
70
60
50
40
30
20
10
0
25-39 years
40-64 years
65+ years
Age of Onset
Ishihara, J Neurol Neurosurg Psych 2007;78:1304-1309
Life Expectancy
Condition
Average Life Expectancy
ALS
3-5 years after diagnosis; 20% alive at 5 years
Huntington’s
15 years after diagnosis
Multiple Sclerosis
5-10 years less than unaffected individuals
PSP
7 years after diagnosis
LTCI Paid Claims Experience
Neurodegenerative Disorders – Duration of Claim
All Other
ALS
Huntington's
Closed
Open
Total
MS
Tremor
Parkinsons
0
2
4
6
8
Duration in Years
Univita LTCI Underwriting and Claims Data Base 2012
Neurodegenerative Disorder Claims in LTCI
CAN LTCI CLAIMS FROM
NEURODEGENERATIVE DISORDERS
BE MANAGED?
LTCI Paid Claims Experience
Neurodegenerative Disorders – Claim Closure
100%
61.6%
Closure
Rate
90%
80%
9.5%
Recovery
Rate
70%
60%
50%
40%
30%
Deceased
Recovered
20%
10%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Paid Claim Closure
100%
100%
90%
86%
Parkinson's
78%
80%
ALS
MS
70%
60%
56%
50%
All Other
44%
40%
30%
18%
20%
10%
0%
8%
6%
0%
Recovered
5%
0% 0%
Deceased
Exhausted
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Age at Recovery
86%
90%
80%
70%
60%
46% 43%
50%
37%
40%
30%
20%
42%
22%
14%
11%
10%
0%
0%
Parkinson's
≤69 years
MS
70-79 years
All Other
≥80 years
Univita LTCI Underwriting and Claims Data Base 2012
LTCI Claims Experience
Timing of Recovery
Neurodegenerative Disorders versus All Other Diagnoses
70%
67%
60%
56%
50%
Neurodegenerative
All Other
40%
32%
30%
23%
20%
8%
10%
2%
3% 1%
0%
In Deductible
<12 months
12-24 months
>24 months
Univita LTCI Underwriting and Claims Data Base 2012
The Spectrum of Benefit Eligibility
Ineligible
for
Benefits
ADL
Independent
Mild
Cognitive
Impairment
Grey
Zone
Benefit Eligible
Two
ADL Dependencies;
Cognitively Intact
Three or More
ADL
Dependencies
Moderately
Cognitively
Impaired;
ADL’s Intact
Severely
Cognitively
Impaired
6/6 ADL
Dependencies
Coma
The Spectrum of Benefit Eligibility
Initial Benefit Eligibility
Ineligible
for
Benefits
Grey
Zone
ADL
Independent
Mild
Cognitive
Impairment
Parkinson’s
Disease
Benefit Eligible
Two
ADL Dependencies;
Cognitively Intact
Three or More
ADL
Dependencies
Moderately
Cognitively
Impaired;
ADL’s Intact
Severely
Cognitively
Impaired
6/6 ADL
Dependencies
Coma
Careful Benefit Eligibility
Determination is Critical
Parkinson’s Approval Rate: 75.8%
All Other Approval Rate: 89.1%
The Spectrum of Benefit Eligibility
Initial Benefit Eligibility
Ineligible
for
Benefits
ADL
Independent
Mild
Cognitive
Impairment
Grey
Zone
Benefit Eligible
Two
ADL Dependencies;
Cognitively Intact
Three or More
ADL
Dependencies
Moderately
Cognitively
Impaired;
ADL’s Intact
Severely
Cognitively
Impaired
Careful Benefit Eligibility
Determination is Critical
ALS, SNP, HD: >98.5%
All Other Approval Rate: 89.1%
ALS
SNP
HD
6/6 ADL
Dependencies
Coma
The Spectrum of Benefit Eligibility
Ongoing Benefit Eligibility
Ineligible
for
Benefits
ADL
Independent
Mild
Cognitive
Impairment
Grey
Zone
Benefit Eligible
Two
ADL Dependencies;
Cognitively Intact
Three or More
ADL
Dependencies
Moderately
Cognitively
Impaired;
ADL’s Intact
Severely
Cognitively
Impaired
Parkinson’s Disease
Multiple Sclerosis
Tremor
6/6 ADL
Dependencies
Coma
Active Management of Recovery
Parkinson’s Recovery Rate: 8.1%
MS Recovery Rate: 43.8%
Tremor Recovery Rate: 30%
Active LTCI Claims Management
At onset of claim
 Approval rates differ by disease entity
– Higher approval rates for rapidly progressive diseases
– Higher non-approval rates for diseases that wax and wane
 IADL versus ADL
– HD, ALS and PSP more biased towards ADL dependencies
– PD, MS and Tremor claims more biased towards IADL dependencies
At reassessment
 Claims closure
– PD, MS and Tremor have recovery rates from 8-30%
– HD, ALS and PSP typically end in death
Active LTCI Claims Management
Challenges and Obstacles
 Reinstatement of deductible
 There will be obstacles to recovery
– ADL recovery without IADL recovery
– Fatigue and depression are significant comorbidities
 Challenges to adjudication
– Waxing–waning course of disease
– Recovery without IADL recovery
– Fatigue and depression are significant comorbidities
 Potential for fraud (low risk in these disorders)
– Symptoms can be subjective; diagnosis needs to be validated
– LTC Insurance as a means of qualifying for SSI or DI
– Beware of requests for Independent Providers and informal care
LTCI Neurodegeneratives Disorders Claims
CONCLUSIONS
Conclusions
 Neurodegeneratives disorders are uncommon conditions
that have a significant impact on LTCI expenditures
 Claims durations vary significantly between conditions
 Compression of morbidity vary between conditions
 A challenge to adjudicate and actively manage
 Early intervention is important – active claims management
– PD, MS and Tremor present a potential for recovery
– A substantial number will recover during the first 12 months of claim
 Care Management can be very effective
– Encourage close medical follow-up; focus on care in the home
– Reach out to insured’s PCP and care manager; coordinate efforts
– Encourage gait rehabilitation, strengthening, OT important for ADLS
 Recognize and focus on mitigating obstacles to recovery