Number Needed to Treat (NNT): Evaluation Tool Used in Health and Wellness Program.

As life insurance companies evaluate prospective health and wellness programs, one frequently used tool is the number needed to treat (NNT) calculation. It is helpful to identify what the NNT might be for individual components of the program as well as for the whole program when all components are combined.

Correlates and Predictors of NT-proBNP in Life Insurance Applicants.

OBJECTIVES: -To document the various laboratory and demographic/historical correlates of NT-proBNP levels in applicants for life insurance, and to explore the accuracy of a prediction model based on those variables. METHOD: -NT-proBNP blood test results were obtained from 1.34 million insurance applicants between the age of 50 and 85 years, beginning in 2003. Exploratory data analysis was carried out to document correlations with other laboratory variables, sex, age, and the presence of relevant diseases. Further, predictive models were used to quantify the proportion of the variance of NT-proBNP, which can be explained by a combination of these other, easier to determine variables. RESULTS: -NT-proBNP shows the expected, negative correlation with estimated glomerular filtration rate (eGFR) is markedly higher in those with a history of heart disease and is somewhat higher in those with a history of hypertension. A strong, unexpected, negative correlation between NT-proBNP and albumin was discovered. Of the variables evaluated, a multivariate adaptive regression spline (MARS) model automated selection procedure selected 7 variables (age, sex, albumin, eGFR, BMI, systolic blood pressure, cholesterol, and history of heart disease). Variable importance evaluation determined that age, albumin and eGFR were the 3 most important continuous variables in the prediction of NT-proBNP levels. An ordinary least squares (OLS) model using these same variables achieved a R-squared of 24.7%. CONCLUSION: -Expected ranges of NT-proBNP may vary substantially depending on the value of other variables in the prediction equation. Albumin is significantly negatively correlated with NT-proBNP levels. The reasons for this are unclear.

Financial Advisers' and Key Informants' Perspectives on the Australian Industry-Led Moratorium on Genetic Tests in Life Insurance.

INTRODUCTION: Genetic discrimination (GD) in the context of life insurance is a perennial concern in Australia and internationally. To address such concerns in Australia, an industry self-regulated Moratorium on Genetic Tests in Life Insurance was introduced in 2019 to restrict life insurers from using genetic test results in underwriting for policies under certain limits. Financial advisers (FAs) are sometimes engaged by clients to provide financial advice and assist them to apply for life insurance. They are therefore well-placed to comment on GD and the operation of the Moratorium. Despite this, the financial advising sector in Australia has yet to be studied empirically with regards to GD and the Moratorium. This study aims to capture this perspective by reporting on interviews with the financial advising sector. METHODS: Ten semi-structured qualitative interviews were conducted with FAs and key informants and were analysed using thematic analysis. CONCLUSION(S): Participants' level of awareness and understanding of the Moratorium varied. Participants reported mixed views on the Moratorium's effectiveness, how it operates in practice, and perceived industry compliance. Participants also provided reflections on Australia's current approach to regulating GD, with most participants supporting the concept of industry self-regulation but identifying a need for this to be supplemented with external oversight and meaningful recourse mechanisms for consumers. Our results suggest that there is scope to increase FAs' awareness of GD, and that further research, consultation, and policy consideration are required to identify an optimal regulatory response to GD in Australia.

Genetic discrimination by insurance companies in Aotearoa New Zealand: experiences and views of health professionals.

AIMS: Genetic discrimination in insurance is a significant clinical, research and consumer issue. Recently, the Australian life insurance industry introduced a partial moratorium on the use of genetic test results. However, in Aotearoa New Zealand, both life and health insurers can still use genetic results legally to discriminate against applicants. We aimed to document experiences and concerns of New Zealand-based health professionals (HPs) around the potential misuse of genetic test results for insurance purposes. METHODS: We administered an online survey to New Zealand HPs who discuss genetic testing with patients, their experiences regarding the use of genetic test results in insurance and views on regulation. RESULTS: Twenty-three New Zealand HPs responded, 15 of whom worked in genetics clinics, representing >60% of the total New Zealand clinical genetics workforce. Eleven respondents reported having patients who experienced adverse outcomes related to insurance based on genetic results. Respondents reported patients sometimes/often delayed (n=11) or refused (n=4) genetic testing due to insurance concerns. Over 80% of those who answered (n=17/21) believe insurers' use of genetic results should be legally regulated. CONCLUSION: New Zealand HPs have concerns about insurance companies using genetic test results in underwriting, including the effect on patients, and strongly believe government legislation is required.

The Australian moratorium on genetics and life insurance: evaluating policy compared to Parliamentary recommendations regarding genetic discrimination.

Objectives and importance of study: Genetic discrimination is a health policy issue of international concern to clinicians, patients, researchers, and policy makers, and threatens the success of genomic medicine. In Australia, genetic discrimination in life insurance is legal and leads to public health harms, including deterring at-risk individuals from clinically indicated testing. In 2018, a Parliamentary Joint Committee recommended an urgent ban on the use of predictive genetic test results in life insurance underwriting in Australia, to be implemented in a form similar to the UK Code on genetic testing and life insurance. In 2019, the insurance industry, through the Financial Services Council (FSC), introduced a self-regulated moratorium that applies until 2024, but only to life insurance policies up to certain financial limits. The FSC moratorium will be reviewed in late 2022, but has no government oversight. STUDY TYPE: Policy implementation evaluation Methods: We used policy evaluation methods to 1) summarise the key recommendations of the 2018 Parliamentary Committee that are directed towards practical aspects of policy development and content; and 2) assess the level of disparity between the implemented moratorium and the recommendations of the Committee. RESULTS: There is a substantial disparity between the Australian moratorium and the Parliamentary Committee recommendations across key areas, including addressing self-regulation, co-development of policy, protection of tests taken during its term, and similarity with the UK Code. The FSC moratorium offers less protection to consumers than the UK Code on a number of measures, including the level of financial coverage, the involvement of government, certainty provided to individuals who have genetic testing, and the treatment of research results. CONCLUSIONS: The FSC moratorium is a step forward for Australia, but falls short of the Parliamentary recommendations. Further regulation by the Australian Government may be required to achieve the aims of the Parliamentary recommendations and ensure the intended level of consumer protection.

Association of Liver Function Tests with Mortality in an Insurance Applicant Population.

OBJECTIVES: -Determine the relationship between liver function test (LFT) results (GGT, alkaline phosphatase, AST, ALT and albumin) and all-cause mortality in life insurance applicants. METHOD: -By use of the Social Security Master Death File, mortality was examined in 15,272,955 insurance applicants for whom blood samples were submitted to the Clinical Reference Laboratory. There were 268,593 deaths observed in this study population, after an average follow-up time of 10.9 years. Results were stratified by sex and by age less/greater than 60, creating 4 groups. Liver function test values were grouped using percentiles of their distribution within these age/ sex groups - so as to update the results generated in prior publications. Additional models were fit using different exclusions and percentile groups within single year age groups. Also, LFTs were treated as continuous variables and included in Cox models with age and smoking status. RESULTS: -Using the risk of the middle 50% of the population by distribution as a reference, relative mortality observed for GGT and alkaline phosphatase was linear with a steep slope from very low to high values. AST showed a J-shaped association with mortality. ALT showed a low-magnitude inverse correlation with mortality. Albumin demonstrated a higher-magnitude inverse correlation with mortality, especially at values below the median. The overall risk associated with LFTs was durable over at least 10 years of follow-up. CONCLUSION: -Liver function tests show a strong and durable correlation to mortality in a large group of insurance applicants. The durability over time suggests that even older values of LFTs found in medical records could be of use in mortality risk prediction.

Justice for Our Genes: The Case for Genetic Non-discrimination Regulations in the New Zealand Life Insurance Industry.

While most comparable jurisdictions have adopted more restrictive positions, life insurers in New Zealand remain permitted to request the disclosure of predictive genetic test results from applicants, driving up the cost to obtain life insurance for those with known susceptibilities to genetic disease. The permissive approach is now an outlier, and risks disincentivising health care and research innovation, facilitating irrational discrimination, and compounding existing health inequities. This article examines the New Zealand position through a consequentialist lens. It analyses justifications for the status quo, as well as international approaches, before concluding that genetic non-discrimination regulations governing New Zealand's life insurance industry should be introduced to enhance public wellbeing.

Health professionals' views and experiences of the Australian moratorium on genetic testing and life insurance: A qualitative study.

Australian life insurance companies can legally use genetic test results in underwriting, which can lead to genetic discrimination. In 2019, the Financial Services Council (Australian life insurance industry governing body) introduced a partial moratorium restricting the use of genetic testing in underwriting policies ≤ $500,000 (active 2019-2024). Health professionals (HPs), especially clinical geneticists and genetic counsellors, often discuss the implications of genetic testing with patients, and provide critical insights into the effectiveness of the moratorium. Using a sequential explanatory mixed methods design, we interviewed 23 Australian HPs, who regularly discuss genetic testing with patients and had previously completed an online survey about genetic testing and life insurance. Interviews explored views and experiences about the moratorium, and regulation, in greater depth. Interview transcripts were analysed using thematic analysis. Two key themes emerged from views expressed by HPs during interviews (about matters reported to or observed by them): 1) benefits of the moratorium, and 2) concerns about the moratorium. While HPs reported that the moratorium reassures some consumers, concerns include industry self-regulation, uncertainty created by the temporary time period, and the inadequacy of the moratorium's financial limits for patients' financial needs. Although a minority of HPs felt the current industry self-regulated moratorium is an adequate solution to genetic discrimination, the vast majority (19/23) expressed concern with industry self-regulation and most felt government regulation is required to adequately protect consumers. HPs in Australia are concerned about the adequacy of the FSC moratorium with regards to consumer protections, and suggest government regulation is required.

[The actual aspects of medical health and life insurance of members of ships' crews].

The Maritime industry plays one of the key role in world economy, occupying central position in becoming unified system of global transportations. At that, crew members ensure necessary vessel seakeeping and high-quality and safe delivery of cargo under contract of sea transportation. In accordance with requirements of the legislation any employer is obliged to insure health and life of employees under professional duties performance. However, this issue has its own specific aspects in shipping. The article considers in detail procedure of insuring health and life of the crew members, considering current trends in medical care support under professional duties performance on voyage. The key problematic aspects are identified. The corresponding recommendations are proposed.

Genomic discrimination in New Zealand health and life insurance. AGenDA: Against Genomic Discrimination in Aotearoa.

Nil.

Racial/Ethnic Disparities in Health and Life Insurance Denial Due to Cancer among Cancer Survivors.

This study examined racial/ethnic differences in health/life insurance denial due to cancer among cancer survivors after the passage of the Affordable Care Act (ACA). Behavioral Risk Factor Surveillance System data were obtained from 2012-2020. The dependent variable asked: "Were you ever denied health insurance or life insurance coverage because of your cancer?" Cancer survivors were included if they were diagnosed with cancer after the Affordable Care Act (N = 14,815). Unadjusted and adjusted logistic regressions for age, sex, income, and employment provided odds ratios of insurance denial due to cancer across racial/ethnic groups: Non-Hispanic White, Black, and Other/mixed race; and Hispanic. Statistically significant differences (p < 0.05) were found between those who were denied or not denied insurance across sex, age, race/ethnicity, income, and employment. Adjusted regressions found significantly higher odds ratios of insurance denial for Blacks (OR: 3.00, 95% CI: 1.77, 5.08), Other/mixed race (OR: 2.16, 95% CI: 1.16, 4.02), and Hispanics (OR: 2.13, 95% CI: 1.02, 4.42) compared to Whites. Differences were observed across sex, income, and employment. Cancer survivors report racial/ethnic disparities in health and life insurance denial due to their cancer despite policy changes. This may be harmful for those who are already financially vulnerable due to their cancer diagnosis and exacerbate racial/ethnic cancer disparities.

Suicide and Life Insurance.

Much has been written about the history of suicide and, notably, about societies that condemned both the act and the actor, resulting in a perpetuation of suicide being stigmatized in many cultures. One aspect of this perceived stigmatization involves exclusionary clauses in life insurance policies that reject paying benefits to survivor-beneficiaries of the decedent if the decedent has died by suicide within a prescribed time frame. From the perspective of the individual, life insurance is designed to protect the estate of a decedent from a significant financial burden. From the insurer's perspective, there are essentially 2 reasons for having a suicide exclusion clause: limiting risk and preventing or discouraging fraud. This column examines these rationales in light of the estimated few suicides that do occur during exclusionary clause time frames. Observations are made about the effect of these clauses on those impacted by the loss of a loved one who died by suicide within the exclusionary time frame. An examination of the perspectives of both the life insurance industry and the impacted survivors of suicide decedents raises questions about what are reasonable and appropriate exclusionary clause time frames that protect both the insurer and survivor-beneficiaries. The forensic expert consulting on such cases should be cognizant of these competing perspectives and engage in therapeutic assessment whenever possible, identifying opportunities to promote thoughtful suicide postvention.

Genetic risk scores in life insurance underwriting.

Genetic tests that predict the lifetime risk of common medical conditions are fast becoming more accurate and affordable. The life insurance industry is interested in using predictive genetic tests in the underwriting process, but more research is needed to establish whether this nascent form of genetic testing can refine the process over conventional underwriting factors. Here, we perform Cox regression of survival on a battery of genetic risk scores for common medical conditions and mortality risks in the Health and Retirement Study, without returning results to participants. Adjusted for covariates in a relevant insurance scenario, the scores could improve mortality risk classification by identifying 2.6 years shorter median lifespan in the highest decile of total genetic liability. We conclude that existing genetic risk scores can already improve life insurance underwriting, which stresses the urgency of policymakers to balance competing interests between stakeholders as this technology develops.

Health and life insurance-related problems in very long-term cancer survivors in Germany: a population-based study.

PURPOSE: Limited research suggests that cancer survivors have problems with insurance. Our study aimed to gain insight into the proportion of very long-term (14-24 years post-diagnosis) survivors of breast, colorectal, and prostate cancers who had problems with health (HI) and life (LI) insurance. METHODS: We used data from CAESAR (CAncEr Survivorship-A multi-Regional population-based study). Participants completed questions on change in insurance providers since cancer diagnosis, problems with requesting (additional) HI or LI, and how potential problems were resolved. We conducted logistic regression to determine factors associated with change in statutory HI. RESULTS: Of the 2714 respondents, 174 (6%) reported having changed HI providers. Most switched between different statutory HI providers (86%), 9% from statutory to private, and 5% from private to statutory. Respondents who changed statutory HI providers were more likely to be prostate cancer survivors (OR 2.79, 95% CI 1.01-7.68) while being ≥ 65 years at time of diagnosis (OR 0.58, 95% CI 0.35-0.96) and having ≥ 2 comorbid conditions (OR 0.61, 95% CI 0.40-0.92) were associated with reduced odds for change. Problems in changing HI were minimal and were resolved with additional contribution. Of the 310 respondents who tried to get LI, 25 respondents reported having difficulties, of whom the majority had their request rejected. CONCLUSION: Most cancer survivors did not change their HI nor tried to buy LI after cancer diagnosis. Problems with changing statutory HI were generally resolved with additional contribution while the main problem encountered when buying LI was rejection of request.

A step forward, but still inadequate: Australian health professionals' views on the genetics and life insurance moratorium.

BACKGROUND: In 2019, the Australian life insurance industry introduced a partial moratorium (ban) limiting the use of genetic test results in life insurance underwriting. The moratorium is industry self-regulated and applies only to policies below certain financial limits (eg, $500 000 of death cover). METHODS: We surveyed Australian health professionals (HPs) who discuss genetic testing with patients, to assess knowledge of the moratorium; reported patient experiences since its commencement; and HP views regarding regulation of genetic discrimination (GD) in Australia. RESULTS: Between April and June 2020, 166 eligible HPs responded to the online survey. Of these, 86% were aware of the moratorium, but <50% had attended related training/information sessions. Only 16% answered all knowledge questions correctly, yet 69% believed they had sufficient knowledge to advise patients. Genetics HPs' awareness and knowledge were better than non-genetics HPs' (p<0.05). There was some reported decrease in patients delaying/declining testing after the moratorium's introduction, however, 42% of HPs disagreed that patients were more willing to have testing post-moratorium. Although many (76%) felt the moratorium resolved some GD concerns, most (88%) still have concerns, primarily around self-regulation, financial limits and the moratorium's temporary nature. Almost half (49%) of HPs reported being dissatisfied with the moratorium as a solution to GD. The majority (95%) felt government oversight is required, and 93% felt specific Australian legislation regarding GD is required. CONCLUSION: While the current Australian moratorium is considered a step forward, most HPs believe it falls short of an adequate long-term regulatory solution to GD in life insurance.

The Social Survey, the Metropolitan Life Insurance Company, and the Beginnings of the US Public Health Service's Sickness Surveys.

The earliest sickness survey of the US Public Health Service, which started in 1915, was the Service's first socioeconomic study of an industrial community. It was also the first to define illness as a person's inability to work. The survey incorporated the Metropolitan Life Insurance Company's definition of illness, which, instead of sickness rates, focused on duration of illness as a proxy of time lost from work. This kind of survey took place in the broader context of the reform movements of the Progressive Era and the social surveys conducted in the United States, which led to the creation of the Federal Commission on Industrial Relations, where the Service's sickness survey originated. The Service's focus on the socioeconomic classification of families and definition of illness as the inability to work enabled it to show the strong link between poverty and illness among industrial workers. The leader of the survey, Edgar Sydenstricker, and the Metropolitan Life Insurance Company came up with new ways to measure the health of the population, which also influenced the Service's studies of the effects of the Great Depression on public health and the National Health Survey of 1935-1936. (Am J Public Health. 2021; 111(11):1960-1968. https://doi.org/10.2105/AJPH.2021.306454).

Study protocol: the Australian genetics and life insurance moratorium-monitoring the effectiveness and response (A-GLIMMER) project.

BACKGROUND: The use of genetic test results in risk-rated insurance is a significant concern internationally, with many countries banning or restricting the use of genetic test results in underwriting. In Australia, life insurers' use of genetic test results is legal and self-regulated by the insurance industry (Financial Services Council (FSC)). In 2018, an Australian Parliamentary Inquiry recommended that insurers' use of genetic test results in underwriting should be prohibited. In 2019, the FSC introduced an industry self-regulated moratorium on the use of genetic test results. In the absence of government oversight, it is critical that the impact, effectiveness and appropriateness of the moratorium is monitored. Here we describe the protocol of our government-funded research project, which will serve that critical function between 2020 and 2023. METHODS: A realist evaluation framework was developed for the project, using a context-mechanism-outcome (CMO) approach, to systematically assess the impact of the moratorium for a range of stakeholders. Outcomes which need to be achieved for the moratorium to accomplish its intended aims were identified, and specific data collection measures methods were developed to gather the evidence from relevant stakeholder groups (consumers, health professionals, financial industry and genetic research community) to determine if aims are achieved. Results from each arm of the study will be analysed and published in peer-reviewed journals as they become available. DISCUSSION: The A-GLIMMER project will provide essential monitoring of the impact and effectiveness of the self-regulated insurance moratorium. On completion of the study (3 years) a Stakeholder Report will be compiled. The Stakeholder Report will synthesise the evidence gathered in each arm of the study and use the CMO framework to evaluate the extent to which each of the outcomes have been achieved, and make evidence-based recommendations to the Australian federal government, life insurance industry and other stakeholders.

Finance 101 for Physicians.

Although physicians enjoy extensive educational backgrounds, financial planning typically is not a significant component of the curricula they have completed. As a result, many physicians could benefit from greater financial acumen, and their preparation for retirement might be lacking in light of their relatively high-income levels. This article by a private wealth advisor with 29 years of industry experience provides physicians with the basic building blocks to understand and manage their finances. It focuses on 3 pillars of financial planning: (1) protecting themselves, their families, and their assets; (2) reducing their taxes; and (3) growing their wealth.

Long COVID - An Early Perspective.

A new syndrome called "Long COVID" has emerged amongst the survivors of acute COVID-19 infection. Its protracted and debilitating nature will almost certainly result in many short and long-term disability claims. Insurers need to understand the nature of Long COVID, including its definition, its prevalence, its natural history, and underlying risk factors. This article will summarize current knowledge of Long COVID and provide a perspective on its evolution and its impact.