Spinal Disorders Claims in
Long Term Care Insurance
It’s such a pain, why bother?
Stephen K. Holland, MD
Chief Medical Officer
Univita Health, Inc.
Long Term Care International Forum, May 2011
Albuquerque, New Mexico
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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
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
3
Spinal Disorders
Understanding
LTCI Claims
Experience
4
LTCI Claims Experience

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
Univita LTCI Underwriting and Claims Data Base 2011
5
LTCI Claims Experience

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
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience


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
Univita LTCI Underwriting and Claims Data Base 2011
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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%
*Accounts for 80% of Paid Claims
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
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
•
•
•
•
Spinal Disorders 4.3%
Other than Spinal
Disorders 95.7%
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
Univita LTCI Underwriting and Claims Data Base 2011
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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 2011
10
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
Median
$78,315
$15,874
$79,679
$56,588
$67,857
$76,830
$38,852
$43,658
$69,532
$34,766
$54,899
$4,024
$51,854
$26,406
$49,050
$53,119
$16,866
$23,575
$41,921
$21,699
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
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)
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Age Distribution
60%
Spinal Disorders versus All Other Diagnoses
50%
40%
Spinal
Disorders
30%
All Others
20%
10%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Gender Distribution
90%
Spinal Disorders versus All Other Diagnoses
80%
Spinal
Disorders
70%
All Others
60%
50%
40%
30%
20%
10%
0%
Female
Male
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Spinal Disorders Location of Care
Assisted Living
28.6%
Nursing Home
8.9%
Home Health
Care
62.4%
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
70%
Spinal Disorders versus All Other
Location of Care
60%
Spinal
Disorders
50%
All Others
40%
30%
20%
10%
0%
Home Health
ALF
SNF
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Spinal Disorders – Claim Closure
100%
90%
70%
Closure
Rate
80%
70%
60%
50%
Deceased
Recovered
40%
30%
20%
10%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Claim Closure
60%
Spinal Disorders versus All Other Diagnoses
50%
Spinal
Disorders
40%
All Others
30%
20%
10%
0%
Recovered
Deceased
Exhausted
Univita LTCI Underwriting and Claims Data Base 2011
18
LTCI Claims Experience
Claim Closure
80%
Spinal Disorders versus All Other Diagnoses
70%
60%
Spinal
Disorders
50%
All Others
40%
30%
20%
10%
0%
Recovered
Deceased
Exhausted
Univita LTCI Underwriting and Claims Data Base 2011
19
LTCI Claims Experience
Age at Recovery
45%
40%
35%
30%
Spinal Disorders versus All Other Diagnoses
Spinal
Disorders
All Others
25%
20%
15%
10%
5%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Age at Recovery
45%
40%
35%
30%
Spinal Disorders versus All Other Diagnoses
Spinal
Disorders
All Others
25%
20%
15%
10%
5%
0%
≤69 years
70-79 years
≥80 years
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
Timing of Recovery
60%
Spinal Disorders versus All Other Diagnoses
50%
Spinal
Disorders
40%
All Others
30%
20%
10%
0%
In Deductible
≤12 months
12-24 months
Univita LTCI Underwriting and Claims Data Base 2011
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LTCI Claims Experience
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
Univita LTCI Underwriting and Claims Data Base 2011
23
Spinal Disorder Claims in LTCI
Can LTCI Claims for
Spinal Disorders be Managed?
24
The Spectrum of Benefit Eligibility
Benefit Eligible
Grey
Zone
6/6 ADL
Three or More Two
Dependencies ADL
ADL Dependencies;
Dependencies Cognitively Intact
Coma
Severely
Cognitively
Impaired
Moderately
Cognitively
Impaired;
ADL’s Intact
Ineligible
for
Benefits
ADL
Independent
Mild
Cognitive
Impairment
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The Spectrum of Benefit Eligibility
Ineligible
for
Benefits
Grey
Zone
Benefit Eligible
6/6 ADL
Three or More Two
Dependencies ADL
ADL Dependencies
Dependencies
ADL
Independent
Careful Benefit Eligibility
Determination is Critical
Spinal Disorder Approval Rate: 72.4%
All Other Approval Rate: 89.1%
Spinal
Disorders
26
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
27
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
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LTCI Spinal Disorder Claims
Conclusions
29
Conclusions

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
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Questions
and
Discussion
LTCIF
Albuquerque, NM
May 2011
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