The Doctors’ Challenge 2013 LTCIF New Orleans, LA


The Doctors’ Challenge

2013 LTCIF

New Orleans, LA

Today’s Panel

• Dr. Stephen Holland

Chief Medical Officer, Univita Health

• Dr. Bruce Margolis

Medical Director, Genworth Financial

• Dr. Bryan Yanaga

Medical Director, Bankers Life and Casualty

Session Format

• 6 cases will be reviewed

• Case details shared for each case

• Discussion lead by one panelist with input from others

• Questions/comments from the audience are welcome

• Chance for you to ask about your tough cases

Case # 1 – UW

(Dr. Holland)

All too typical LTCI applicant

58 years old male, applying for a 6-year LTC policy, 90 day EP, $300/day, spouse disc

 History of hypertension on metoprolol 25 mg daily and HCTZ 25 mg. daily

 Sedentary, no regular exercise, non-smoker, 1 glass a wine daily

 Family history: Father deceased age 79 d/t MI, Mother alive with Alzheimer’s age



– 3-4 visits per year for health maintenance, dietary counseling

– BPs average 134/90, normal physical exam, BMI 32

– Labs: Normal electrolytes, Creat/BUN normal, CBC normal, FBS 123mg%

– Lipids: Cholesterol 240 mg/dl, HDL 32 mg/dl, LDL 132 mg/dl, Triglycerides 220 mg/dl

– EKG: Normal

– Chest x-ray: Normal

– Colonoscopy: Normal

Case # 1 – UW

(Dr. Holland)

Underwriting Questions:

– Is this gentleman insurable?

– At a Standard Rating?

– For the policy requested?

Case # 2 – UW

(Dr. Margolis)

What’s the LTC Risk?

– 55 yo male; applying $235/day, 5 years, 90 day EP

– Build: 5’10”/250lbs (BMI 36)

– Notes HTN on Micardis® and metoprolol; non-smoker

– Has a PCP and a cardiologist

– Works as a civil engineer

– Father deceased age 70 - CVA

– Prescription drug report – consistent with application

– Medical records:

• HTN, hyperlipidemia, OSA on CPAP

• FBS 122mg%; BUN/Cr 14/1.0; cholesterol141mg/dl; triglycerides 192 mg/dl; HDL 39 mg/dl; cholesterol/HDL ratio 3.6

• Nuclear stress test 4/12 - negative

• Carotid doppler 4/12 - mild plaque right ICA; no stenosis

• Echocardiogram 3/12 – mild LVH, no VHD, mild dilation aortic root

• CT chest 3/12 – stable 4cm ascending aortic aneurysm unchanged from

11/07; calcification left coronary artery

Case # 2 – UW

(Dr. Margolis)

Underwriting Questions:

– What’s the overriding diagnosis?

– Is the ascending aortic aneurysm of concern? Risk of rupture?

– What’s his cardiovascular risk?

– Is he insurable?

Case # 3 – UW

(Dr. Yanaga)

A Common Presentation

– 63-year old woman, $150/day, 3 years, 30 day EP

– Said to be physically active and in excellent health

– HTN, hyperlipidemia

– Hyzaar, Crestor

– Lap band surgery 9 months ago. Lost a total of 70 lbs

• 5’5”, 210 lbs (APP), BMI = 34.9

• 5’5”, 230 lbs (APS), BMI = 38.3

– At her most recent PCP visit she complained of a 4-6 week history of right ankle pain that began after walking her grandchildren to school

(0 to 3 out of 10 at rest. 3 to 6 out of 10 with ambulation.) She was referred to PT by her podiatrist, but never attended. No diagnostic testing has been performed.

Case # 3 – UW

(Dr. Yanaga)

Underwriting Questions:

– How will you rate for Build?

– How will you rate for Build in the face of recent weight loss?

– How will you rate for Pain?

Case # 4 – CL

(Dr. Holland)

A Case of Too Much Holiday Cheer – Part 1

 78 years old male found at home at Christmas, disoriented and confused

TQ LTCI Policy Effective Date: 7/1/1996, 5 year, 90 day EP, $300/day, spouse disc

 Hospitalized for delirium, creatinine 8.2 mg/dl, BUN 100, glucose: 532 mg%, BAC


Diagnosis: Diabetic nephropathy, ETOH, chronic renal failure, dementia; dialysis begun

 Discharged to nursing home after 21 day hospital stay in a debilitated state

 MDS: Renal failure, diabetes, dementia, 4 of 6 ADL dependent, poor decision making

 Medical Records were obtained

– Diagnoses of diabetes, chronic renal failure on hemodialysis (twice weekly), dementia

– Rx: insulin, low protein diet, beta blocker

 Working with Care Manager, discharged to ALF after 45 day nursing home stay

Attending MD sends in Carrier’s Chronically Ill Statement stating 4/6 ADL + Cognitive

 Eligibility approved, benefits begin

When and how would you reassess this claimant?

Case # 4 – CL

(Dr. Holland)

A Case of Too Much Holiday Cheer – Part 2

 Reassessment at 90 days

- ALF records reviewed, ongoing assistance with 2 of 6 ADLs, poor decision making,

- Dialysis once a week

- Chronically Ill Statement sent in from attending MD

 Medical Records obtained

– Diagnoses of diabetes, chronic renal failure on hemodialysis (weekly), dementia

– Rx: insulin, low protein diet, beta blocker

– Note in medical record that patient adjusting to ALF, home has been sold

 Approved for ongoing benefits

When and how would you reassess this claimant?

Case # 4 – CL

(Dr. Holland)

A case of too much Holiday Cheer – Part 3

Reassessment at 45 days

ALF records received: ongoing assistance with 2 of 6 ADLs, poor decision making,

No mention of dialysis, “resident adjusting well to surroundings”

At family’s request, Chronically Ill Statement once again sent in from attending

MD stating 4 of 6 ADL dependencies and ongoing cognitive impairment

 Invoices reviewed

– Room and Board only, several over night trips billed to claimant

When and how would you proceed?

 In-person assessment and review of actual ALF care notes

Results of assessment and investigation

 In-person assessment showed completely ADL independent, self-administers medications, no dialysis, no ongoing personal care other than IADLs in medical record, leaves facility often without an escort (bingo and horse races) – CLAIM


Case # 5 – CL

(Dr. Margolis)

A Claim or Not a Claim – That is the Question

– 60 yo female calls in to open a claim

– TQ Policy, Effective Date: 1/17/2006, 3 year, 90 day EP, $150/day

– Insured states has lost parents and spouse past 18 months

– Feels depressed and has developed problems with word finding and concentration; trouble getting out of bed; getting lost

– PCP declines to submit information; refers us to insured’s psychologist and psychologist

– Psychologist submits letter sent for SSDI determination in 11/12

• Several year history of MDD with three psychiatric hospitalizations

• Notes decline in memory and concentration; easily overwhelmed; confused at times; disorganized; forgets medication and bathing; purchased car she could not afford

• Dx: MDD with psychotic features, fibromyalgia; GAF 35

Case # 5 – CL

(Dr. Margolis)

A Claim or Not a Claim – That is the Question (cont.)

– In-home assessment

• Lives alone in own home

• Needs reminders for bathing and dressing; partially dependent for most


• MMSE 29/30

• On anti-depressant and anti-anxiety medication

• Can spend days in her pajamas

• Two accidents while driving – cut corners too closely and blew out tires

Claim Questions:

– Is insured cognitively impaired?

– Could there be an associated dementia?

– Does the insured meet HIPAA definition of (severe) cognitive impairment?

– Any other work up necessary?

Case # 6 – UW

(Dr. Yanaga)

A TIA By Any Other Name…

– 74-year old man, $150/day, 3 years, 30 day EP

– Type 2 Diabetes (HbA1c=6.2), hyperlipidemia

– Metformin, Lipitor

– Smokes 1-2 cigarettes per day for 10 years

– 12-months ago he presented one day following an episode of mental confusion and right-sided weakness. Witnessed by his wife.

Symptoms resolved after 2 hours.

– 5’8”, 180 lbs (APP), BMI = 27.4

– Neurological exam: Negative

– MRI of the brain without contrast: Minimal age-related atrophy

– MRA of the head: Normal intracranial circulation and circle of Willis

– Recently received a letter from primary care physician: “He did not have a TIA. His symptoms were due to the use of Daliresp”.

Case # 6 – UW

(Dr. Yanaga)

Underwriting Questions:

– Will you rate for history of TIA?

– What value do you place on the information provided by the primary care physician?

Audience Cases

Thank You!