Now on to
Laparoscopic Adjustable Gastric Band
LTCI Underwriting and Claims in the Midst
of an Epidemic of Obesity
Long Term Care International Forum
Tampa, Florida
May 2010
Stephen K. Holland, MD
Medical Director
Univita, Inc.
sholland@univitahealth.com
508.651.8800
1
Laparoscopic Adjustable Gastric Band
 Approved
by FDA in June 2001
 Second most common performed bariatric surgery
 Most common weight loss surgery in Europe, Australia
and Latin America
 Ease of placement
 Less than 60 minute operating time
 Low morbidity
 Very low mortality
 Short hospital stays (migrating rapidly to outpatient)
 A heavily promoted medical device
2
Laparoscopic Adjustable Gastric Band
3
4
5
6
Laparoscopic Adjustable Gastric Band
Complications

Gastric prolapse (aka slip): 5
5-15%
15%

Gastroesophageal dilation: 5-10%

B d erosion:
Band
i
0
0-2%
2%

Inaccessible Port: 2-5%

Pain at adjustment port site: 1-2%

Vitamin deficiency: <1%

Leaking port: 5%

Revisions 9-15%; Explants: 9-12%
Allen, JW. Laparoscopic Gastric Band Complications. Med Clin of N Amer 2007; 91:485-497.
Martin, LF, et.al. Treating morbid obesity with laparoscopic adjustable gastric banding. Ame J of Surg 2007; 194:333-343.
7
Review of Two Multicenter Surgical Trials
Prospective, open-label, single-arm surgical trials
Trial A:
A 292 subjects,
s bjects mean weight:
eight 133 kg ±24.4
±24 4 kg
Trial B: 193 subjects, mean weight: 129 kg ±20.8 kg
R
Results
lt

12 months after surgery
 Initial body
y weight
g lost ((%):
) Trial A:17.7% ± 9.4%,, Trial B:18.2% ±8.2%

Complications in 66-76% patients (mostly gastrointestinal symptoms)

Minimal further weight loss at 3 years

At nine
i years after
ft surgery: 33% off patients
ti t had
h dd
devices
i
explanted
l t d

Generally as a result of complication or inadequate weight loss
Martin, LF, et.al. Treating morbid obesity with laparoscopic adjustable gastric banding. Ame J Surg 2007;194:333-343.
8
Lap
p Gastric Banding
g and Type
yp 2 Diabetes
Author
Subjects
Pre-op
BMI
Follow-up
Weight Loss
Pre versus Post
HgbA1c
Response
Dixon
500
48
1 year
38% EWL
7.8 versus 6.2
R = 64%
I = 26%
U = 10%
Pontiroli
143
45
3 years
BMI 45->37
8.3 versus 5.3
R = 80%
Ponce
413
49
3 years
52 5% EWL
52.5%
7 2 versus 5.3
7.2
53
R = 80%
I = 20%
73 LABG
49 Controls
46
45
4 years
BMI 46->48
No Change
9.4 versus 8.0
8.6 versus 8.6
R = 45%
R = 4%
Pontiroli
Response: R = Remission, I = Improved; U = Unchanged
Smith, B.R., et.al. Surgical Approaches to the Treatment of Obesity: Bariatric Surgery.
Endocrinol Metab Clin N Am 2008; 27:943-964.
9
Long Term Outcomes
• Swedish prospective, controlled study of obese
individuals
• Enrolled 4047 subjects who either underwent bariatric
surgery or received conventional treatment
• Close follow-up for up to 15 years
• Study suggests that bariatric surgery for severe obesity
is associated with long-term weight loss and decreased
overallll mortality
t lit
Sjostrom L et al. New England J Med 2007;357:741-752
10
Mean Percent Weight Change during a 15-Year Period in the Control Group and the Surgery
Group, According to the Method of Bariatric Surgery
Sjostrom L et al. New England J Med 2007;357:741-752
11
LTCI Underwriting Applicants with Bariatric Surgery
• Sufficient duration of p
post-operative
p
stability
y
– At least 24 months with 6 months of weight stability
– Complications free for at least 12 months
– Good medical follow
follow-up
up (seen at least twice a year)
• Weight and clinical goals attained
– Body Mass Index of 30 or less
– Comorbidity such as diabetes and hypertension in remission
• Active and Independent, no limitations
12
LTCI Underwriting in the Midst
of an Epidemic
p
of Obesity
y
Long Term Care International Forum
Tampa, Florida
May 2010
13
Market Realities
- Tension Sales & Marketing


GI and Modified GI
Rapid underwriting
- No medical records
- Minimize screening
g
- Tele-underwriting
Risk Management


Underwriting
g is essential
More Underwriting
- APS for all
- Cognitive Screens
- Specialty records
14
Information Sources are less than Perfect
 LTCI
-
Application
Agent and applicant bias
 Phone
-
Interviews (PHI)
Self reporting in an insured environment
 Medical
M di l
-
R
Records
d (APS)
Often incomplete
Often filled with conjecture
j
and inadequate
q
work
work--ups
p
 Face
Face--toto-Face
-
A snapshot in time
Rudimentary cognitive screening tools
 Specialty
-
Assessments (F2F)
Records (SAPS)
Often unavailable or difficult to obtain
15
Utility of Admitted Health History
Underwriting Data by Source of Data
Data Analysis: 134,346 applicants

Average age: 55.6 years

Age ≤65 years: 87.6%

Age >65 years: 12.4%
Compared diagnoses admitted on:

Application

Phone Interview
to significant diagnoses found in their APS.
Univita LTCI Underwriting and Claims Data Base 2010
16
Integrity of the LTCI Application
Can we rely only on an LTCI Application?
Disclosed on Application
Not Disclosed on
Application, but Found
in APS
Diabetes
68 9%
68.9%
31 1%
31.1%
Stroke/TIA
38.4%
61.6%
Fractures
38.7%
61.3%
Hypertension
76.5%
23.5%
Falls
0%
100%
Memory Complaints,
Dementia
4.1%
95.9%
Univita LTCI Underwriting and Claims Data Base 2010
17
Veracity
y of the LTCI Phone Interview
Can we rely solely on a phone interview?
Disclosed during PHI
Not Disclosed during PHI,
but Found in APS
Diabetes
68.6%
31.4%
Stroke/TIA
23.7%
76.3%
Fractures
17.5%
82.5%
Hypertension
70.4%
29.8%
Falls
8.5%
91.5%
Memory Complaints,
Dementia
5.4%
94.6%
Univita LTCI Underwriting and Claims Data Base 2010
18
BMI at Time of Application
pp
14.0%
12.0%
10.0%
8 0%
8.0%
6.0%
4.0%
2.0%
0.0%
14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 59 61
BMI from Application
19
BMI at Time of Application
pp
10.0%
9.0%
8.0%
7.0%
6 0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 55 61
BMI from PHI
20
BMI at Time of Application
pp
10.0%
9.0%
8.0%
Shift tto hi
higher
h BMI
7.0%
6 0%
6.0%
5.0%
4.0%
3.0%
2.0%
1 0%
1.0%
0.0%
14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 53 58
Measured BMI from Face-to-Face Assessment
21
Stated versus Measured Weight

Applications: Stated weight

APS and F2F assessments: Measured weight
g

Comparison
- Normal
weight:
g misstate weight
g +/+/- 0.8 lbs.
- Extremes
of weight
 BMI
<19.0: Overstate weight by 6.5 lbs. on average
 BMI
2525-29.9: Understate weight 3.4 lbs. on average
 BMI
3030-39.9: Understate weight 8.1 lbs. on average
 BMI
≥40:
40 U
Understate
d t t weight
i ht 22 lb
lbs. on average
At the extremes of weight,
a measured
d weight
i ht is
i essential
ti l
22
Underwriting Obesity


BMI cutcut-offs vary by carrier at the extremes

Maximum: BMI 35 to 42

Minimum: BMI 18.0 to 19.5
Univita’s Approach

Recent measured weight at the extremes

Maximums and Minimums:
- Standard up
p to BMI 35 and rated risk class
class: BMI 35 to 40
- Standard down to 19.5 and rated risk class: BMI 19.5 to 18
Underwriting scrutiny intensifies at the extremes
Increased Risk
BMI
Increased Risk
23
Univita Claims Data Base


TQ Group LTCI policy
 73% Comprehensive, 22% Facility only, 4% Partnership
 Average age of active members: 56.6 years
 Gender: 60% Female, 40% Male
 Average policy duration: 10.7 years (maximum 16+ years)
 Total exposure: 23
23,800,127
800 127 member months
Claims Experience
 19,882 Requests for LTCI Benefits
 15,148 Approved LTCI Claims
 11,112 Paid LTCI Claims
 $638 million in Benefits Paid to Date
 Average Paid Claim: $57,449
 Claim Closure
- 3,423
Recoveries; 7,152 Deaths, 331 Exhausted Benefits
Univita LTCI Underwriting and Claims Data Base 2010
24
2005 Obesity Claims Experience
2005 Claim Rate/1000 covered months
Normal Weight: 0.47 & Obese: 0.33
0 70
0.70
0.60
Paid Claims
per 1000
covered
months
0 50
0.50
0.40
0.30
0.20
0.10
-
BMI <30
30
Univita LTCI Underwriting and Claims Data Base 2010
BMI 30-40
30 40
BMI >40
40
25
Is Obesity an LTCI Burden?
2010 Claim Rate/1000 covered months
Normal Weight: 1.06 & Obese: 0.86
1.2
1.0
Paid Claims
0.8
per 1000
covered
0.6
months
0.4
02
0.2
19.0
24.9
19.0-24.9
25.0
25.9
25.0-25.9
Body Mass Index
Univita LTCI Underwriting and Claims Data Base 2010
30.0
39.9
30.0-39.9
26
Is Obesity an LTCI Burden?
2010 Claim Rate/1000 covered months
Underweight: 1.69 Normal Weight: 1.06 & Very Obese: 0.80
18
1.8
1.6
1.4
Paid Claims
1.2
per 1000
covered
1.0
months
08
0.8
0.6
0.4
0.2
<19.0
<19 0
19.0-24.9
19 0 24 9
25.0-25.9
25 0 25 9
30.0-39.9
30 0 39 9
≥40 0
≥40.0
Body Mass Index
Univita LTCI Underwriting and Claims Data Base 2010
27
2005 Obesity Claims Experience
2005 Loss Ratio
Normal Weight: 0.16 & Obese: 0.14
0 50
0.50
0.45
0.40
Loss 0.35
0 35
Ratio 0.30
0.25
0.20
0.15
0.10
0.05
65-74 yrs NL
WT
65-74 yrs
Obese
Univita LTCI Underwriting and Claims Data Base 2010
75-84 yrs NL
WT
75-84 yrs
Obese
28
Compression of Morbidity: Obesity
2010 Loss Ratio
Normal Weight: 0.83 & Very Obese: 1.27
1.4
1.2
Crude
Loss
Ratio
10
1.0
0.8
06
0.6
0.4
0.2
<19.0
19.0
19.0-24.9
19.0
24.9
25.0-29.9
25.0
29.9
30.0
30.0-39.9
39.9
≥40.0
Body Mass Index
Univita LTCI Underwriting and Claims Data Base 2010
29
Compression of Morbidity: Obesity
2010 Loss Ratio Age ≥75 Years
Normal Weight: 1.53 & Very Obese: 0.83
2.0
1.8
1.6
Crude
Loss
Ratio
1.4
14
1.2
1.0
0.8
0.6
0.4
0.2
<19.0
19.0
19.0-24.9
19.0
24.9
25.0-29.9
25.0
29.9
30.0
30.0-39.9
39.9
≥40.0
Body Mass Index
Univita LTCI Underwriting and Claims Data Base 2010
30
Compression of Morbidity: Obesity
2010 Loss Ratio Age 65-74 Years
Normal Weight: 0.94 & Very Obese: 2.15
2.5
2.0
Crude
Loss
Ratio
1.5
1.0
0.5
<19.0
19.0
19.0-24.9
19.0
24.9
25.0-29.9
25.0
29.9
30.0
30.0-39.9
39.9
≥40.0
Body Mass Index
Univita LTCI Underwriting and Claims Data Base 2010
31
Conclusions

Obesity is prevalent in LTCI applicant pool

Bariatric surgery is a common therapy for obesity

Little claims experience data for those with bariatric surgery

At the extremes
extremes, stated weight is often exaggerated

Intense UW scrutiny at extremes may be countercounter-productive


After 12+ years claim rates increase at extreme weight

Intense underwriting may counteract Obesity’s Compression of
Morbidityy
Obesity will continue to be a be a challenge for both LTCI
underwriting and claims
32
LTCI Underwriting and Claims in the Midst
off an Epidemic
E id i off Obesity
Ob it
Questions
&
Discussion
Long Term Care International Forum
Tampa, Florida
May 2010
33