May 9, 2013
Fibromyalgia
Stephen K. Holland, MD
Chief Medical Officer
Univita Health, Inc.
Long Term Care International Forum, New Orleans
Agenda
•
Amen to underwriting
•
How common are LTCI claims for fibromyalgia?
•
One Carrier’s LTCI claims experience
•
Can we actively manage fibromyalgia claims?
•
Conclusions
Fibromyalgia 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
Fibromyalgia
Understanding LTCI Claims Experience
LTCI Claims Experience
Carrier A - TQ Group LTCI policy

150,000 active members, Average Issue Age 69.0 years

73% Comprehensive, 22% Facility-only, 4% Partnership

Gender: 60% Female, 40% Male

Average policy duration: 11.7 years (max 17+ years)

Over 16,840 paid claims, average paid claim: $66,816

Paid Claims: 75% Closed, 25% Open; attained age 81.5 years

29% recovered, 68% deceased, 2.6% exhausted benefits

-
Average Open Claim: $93,067, Average Recovered Claim: $23,111
-
Average Deceased Claim: $58,821, Average Exhausted Claim: $116,376
2.5 million member years of exposure, $1.125B paid to date
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience


Risk Pool Disability Profile
-
25% Cognitive Impairment (CI)
-
45% 2+ ADL dependency
-
30% Combined ADL dependency & CI
Setting of Care
-
56.8% Home Health Care
-
30.5% Assisted Living
-
12.7% Nursing Home
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Most frequent paid claimed events*
1. Pure Dementia
2. Cancer
3. Stroke
4. Fractures/Injuries/Falls/Gait issues
5. Arthritis and other Rheumatic diseases
6. Parkinson’s disease
7. Respiratory disease
8. CHF, Cardiomyopathy
9. Spinal disorders
10.Diabetic complications
24%
14%
11%
7%
5%
5%
4%
4%
4%
2%
*Account for 80% of Paid Claims
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Most frequent paid claimed events
1. Pure Dementia
2. Cancer
3. Stroke
4. Fractures/Injuries/Falls/Gait issues
5. Arthritis &other Rheumatic diseases
6. Parkinson’s disease
7. Respiratory disease
8. CHF, Cardiomyopathy
9. Spinal disorders
10.Diabetic complications
Mean
$78,315
$15,874
$79,679
$56,588
$67,857
$76,830
$38,852
$43,658
$69,532
$34,766
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Most frequent paid claimed events
1. Pure Dementia
2. Cancer
3. Stroke
4. Fractures/Injuries/Falls/Gait issues
5. Arthritis &other Rheumatic diseases
6. Parkinson’s disease
7. Respiratory disease
8. CHF, Cardiomyopathy
9. Spinal disorders
10.Diabetic complications
Fibromyalgia
Mean
Median
$78,315
$15,874
$79,679
$56,588
$67,857
$76,830
$38,852
$43,658
$69,532
$34,766
$68,562
$54,899
$4,024
$51,854
$26,406
$49,050
$53,119
$16,866
$23,575
$41,921
$21,699
$37,584
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
As of 12/31/2012: 22,119 Approved & 16,834 Paid Claims
Fibromyalgia: 639 request for benefits
• 532 approved (83% approval rate) and 421 paid
Fibromyalgia 2.6%
• Age at issue: 70.2 years
• Age at time of claims: 79.9 years
• $28,864,602 paid to date
• $68,562 average claim payment
All others: 27,903 benefit requests
•
•
•
•
•
Other than
Fibromyalgia 97.4%
22, 119 Approved (89% approval rate) and 16,834 paid
Age at issue: 69.2 years
Age at time of claims: 77.3 years
$1.12 Billion paid to date
$66,799 average claim payment
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Typical fibromyalgia claim:





80 years of age, female, living at home
Fibromyalgia complicated by OA and depression
PCP care only
2+ ADL dependencies
Home Health Care, 35 months, $68,322 paid
Most costly claim to date:





84 years of age, female
Fibromyalgia complicated by dementia
PCP care only
5 ADL dependencies + cognitive impairment
Nursing home, 11.4 years, $512,853
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Age Distribution
Fibromyalgia versus All Other Diagnoses
60%
50%
40%
Fibromyalgia
30%
All Others
20%
10%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
70%
Gender Distribution
Fibromyalgia versus All Other Diagnoses
60%
Fibromyalgia
50%
All Others
40%
30%
20%
10%
0%
Female
Male
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Fibromyalgia
Location of Care
Nursing Home
14.5%
Assisted Living
26.4%
Home Care
59.1%
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
70%
Fibromyalgia versus All Other
Location of Care
60%
Fibromyalgia
50%
40%
All Others
30%
20%
10%
0%
Home Health
ALF
SNF
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Fibromyalgia
Claim Closure
100%
90%
82%
Closure
Rate
80%
70%
60%
Deceased
Recovered
50%
40%
30%
20%
10%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
80%
Claim Closure
Fibromyalgia versus All Other Diagnoses
70%
60%
Fibromyalgia
50%
All Others
40%
30%
20%
10%
0%
Recovered
Deceased
Exhausted
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
90%
Claim Closure
Fibromyalgia versus All Other Diagnoses
80%
70%
Fibromyalgia
60%
All Others
50%
40%
30%
20%
10%
0%
Recovered
Deceased
Exhausted
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Age at Recovery
45%
40%
Fibromyalgia versus All Other Diagnoses
Fibromyalgia
35%
30%
All Others
25%
20%
15%
10%
5%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Age at Recovery
45%
40%
Fibromyalgia versus All Other Diagnoses
Fibromyalgia
35%
30%
All Others
25%
20%
15%
10%
5%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Time of Recovery
60%
Fibromyalgia versus All Other Diagnoses
50%
Fibromyalgia
40%
All Others
30%
20%
10%
0%
In Deductible
≤12 months
12-24 months
Univita LTCI Underwriting and Claims Data Base 2013
LTCI Claims Experience
Has there been anti-selection?
– Research on incidence and prevalence of fibromyalgia is sparse
– Little published about the natural history of this disorder
– Very little information on levels of disability
LTC Claims Experience
Dementia
Stroke
Parkinson's
Huntington's
Fibromyalgia
Cases
Cases/1000
Members
4,069
1,686
811
16
421
19.57
8.11
3.90
0.08
2.84
Incidence
per 100K Average
% of Total
Total Payments
Mem Yrs
Paid Claims
Claim
Exposure
162.8
67.4
32.4
0.64
14.0
$88,011
$86,223
$80,221
$140,469
$68,562
$358,118,113
$145,388,054
$65,058,989
$2,247,504
$28,864,602
Less than 10% of Fibromyalgia Claimants
had the Disorder at Time of Application
31.9%
12.9%
5.8%
0.2%
2.6%
Fibromyalgia as a Comorbidity
Primary Diagnosis versus Comorbidity
Cases
Average
Paid
Open
Average
Paid
Closed
Primary
Diagnosis
421
$144,790
Comorbid
788
$125,132
Open/Closed
Approval
Rate
Recovered
$51,770
6.1/2.2 yrs
83%
16%
$39,735
4.9/2.2 yrs
95%
20%
Duration
Claims are Longer and More Expensive when
Fibromyalgia is a Primary Diagnosis
22
Fibromyalgia LTCI Claims
Can LTCI Claims for
Fibromyalgia be Managed?
The Spectrum of Benefit Eligibility
Grey
Zone
Benefit Eligible
6/6 ADL
Dependencies
Three or More
ADL
Dependencies
Two
ADL Dependencies
Ineligible
for
Benefits
ADL
Independent
Careful Benefit Eligibility
Determination is Critical
Fibromyalgia Approval Rate: 83%
Fibromyalgia
All Other Approval Rate: 89.1%
Univita LTCI Underwriting and Claims Data Base 2013
Active LTCI Claims Management
• Higher non-approval rates at claim submission
-
Claimed event heavily biased towards IADL dependencies
• Claim closure a challenge
-
Only 16% of closed claims close via recovery
-
More than 51% recover during deductible period
-
An additional 37% recovery during the next 36 months
• There will be obstacles to recovery
-
IADL abilities slow to recover
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Reinstatement of deductible
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Depression is a major obstacle to recovery
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Significant potential for secondary gain (DI, SSI, etc.)
• There will be fraud
Case Study
31 year old woman, comprehensive, unlimited lifetime benefits,
$200 per day, Annual premium $996. Effective Date 4-1-1995, MGI
1st benefit period
• 5-1-1997 Initial RFB, Financial advisor called stating insured is completely
disabled and is in need of immediate assistance. He thinks she has lupus and
some type of auto immune disorder.
• 5-2-97: requested use of an IP , she has one in mind, Needs an IP as she is
fearful or strangers in her home. Stated she needs help bathing and driving.
• 5-2-97: Initial BEA: 31 year old female residing in a large nicely decorated
impeccable home. Current support includes assist from church members and
mother, reports diagnoses of fibromyalgia, chronic fatigue, immune
dysfunction, chronic pain, arthritis in feet, claimant reports her chronic fatigue
exasperates her fibromyalgia, resulting in severe depression with prolonged
crying, followed by panic attacks.
• BEA shows her to be dependent with B, D and IADL care.
• Medical records requested prior to decision to approve – MD confirms chronic
pain issues resulting in an inability to function and care for self.
• Claimant requests 2 female Independent Providers (IPs)
Case Study
Ongoing Active Claims Management
• 9-1-1997 claims exam notes that IPs replaced with a single male caregiver
– Care Manger inquiries, on-site assessment attempted, claim goes inactive.
• 10-5-1998 request for back payment of IP care from 9-15-1997 to 10-1998,
submits letter from psychiatrist in support of ongoing dependency
– Request for proof of payment, in-person assessment – multiple ADL dependencies
– Surveillance, MD investigated
– Claimant immediately reports that care ended and does not pursue back payment
– Claim put on Fraud Watch Status
2nd Benefit Period 6-2002
• Auto Accident exacerbated fibromyalgia and chronic fatigue
• Onsite assessment 6/6 ADL dependencies, requests IP
• Insurance activity background investigation performed
• Multiple claims with multiple insurers
• IP request denied and no claims submitted
Case Study
3rd Benefit Period 3-2005
• Called in to submit new claim due to exacerbated fibromyalgia and chronic
fatigue
• Referred to original Care Manager
• Insured decided to drop request for benefits
4th Benefit Period 3-2005
• Called in to submit new claim due to exacerbated fibromyalgia and chronic
fatigue
• Referred to original Care Manager
• Insured decided to drop request for benefits
5th Benefit Period 11-2009
• Called in to submit new claim anticipating hysterectomy
• Referred to original Care Manager, requested auth for med records
• No authorization received, RFB closed
Active LTCI Claims Management
Significant potential for fraud

Symptoms are subjective

LTC Insurance as a means of qualifying for SSI or DI

Requests for Independent Providers and informal care

Provider records poorly document daily function
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Pain symptoms predominate
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Provider as advocate

Always entails a significant amount of investigation
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Useful investigatory tools
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Surveillance – direct and social media
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Coordination with other insurers
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Neighbor interviews
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Independent medical exam
Active LTCI Claims Management
What Can We Learn from Acute Care

A disorder in search of a biomarker

Often complicated by depression and fatigue

Pain and limitations wax and wane

Early mobilization and continued activities are critical

Mode of therapy seems less critical

Disabled patients should be managed by a specialist

Active care management can be effective
-
Adequate analgesia and prescribed exercise program
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Home Physical Therapy as bridge to outpatient therapy
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Coaching and self management
Fibromyalgia
LTCI Fibromyalgia Claims
Conclusions
Conclusions

Fibromyalgia is a fairly uncommon LTCI claimed event

Most claims for fibromyalgia are shorter than others

Early intervention is important – active claims management


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Some will recover during their deductible period
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A most recover during the first 12 months of claim
Care Management can be very effective
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Encourage close medical follow-up
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Reach out to insured’s PCP and care manager; coordinate efforts
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Encourage rehabilitation
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A diagnosis highly associated with fraud
Recognize and focus on mitigating obstacles to recovery