The Crown Jewel of Teleunderwriting = Rx

Hank George, FALU, CLU, FLMI
July, 2007 • Teleunderwrtiting Essay 6

 

Introduction

Before I get into this intriguing – and essential – aspect of teleunderwriting, I want to acknowledge that as of today we have 224 underwriters and others registered to read this series of essays.

Wow!

The best part is that you come from all over the world, including Peru, Romania, Italy and all of the major English-speaking markets, including large numbers of chief underwriters in the UK and “down under.”

I invite you to invite your peers in the industry to partake of these essays. What they will learn (not to mention what they will save having to track down or pay for) should make the experience worthwhile.

Now, to the subject at hand, and what better way to introduce it than with this statement:

“Tell me what he’s taking…and I’ll tell you what he’s got!”

I spontaneously uttered this phrase in front of a room packed with Northwestern Mutual life insurance agents on my first ever “agency visit” (the term we used in those days for when underwriters went out to talk and to listen with our sales personnel).

This was indeed spontaneous because I was looking into all these eager sets of eyes and trying to come up with something “profound.”

Perhaps I did, although I didn’t fully appreciate it at the time.

When I was on the medical staff at Northwestern Mutual, we used to have (and I reckon they still do) what we called “operation issue” twice a year, in May and December. On each occasion, we battened down the hatches and tried to get as much pending new business issued as possible.

One of the things that the doctors and I did was to “blitz” cases and see if we could make sound underwriting decisions on the spot.

And one of the drivers of our capacity is embodied in the quote above…if we knew what the applicant was taking, we had the inside track to putting the symptoms, tests, ostensible diagnosis and so on into perspective.

This could result in favorable action on certain complaints like dizziness, chest pain and so on, where we might otherwise have let the file grow moss waiting for medical records we probably didn’t need.

It could also work in the other direction, so to speak. For example, I recall a case where a clergyman (of all people!) said that he had a minor problem, described vaguely, for which he was treated with “citoxin.”

What is “citoxin?”

Actually, it doesn’t exist…

…but “Cytoxan” does. It’s the proprietary name for the anti-cancer drug cyclophosphamide, which is also being used in serious chronic diseases other than malignancy.

A little further probing and what we REALLY HAD here was Stage IVB Hodgkin lymphoma, still undergoing therapy!

Imagine if someone had breezed past this drug name or given up trying to find it due to its being misspelled! Good chance for a death claim, especially back then before we made the tremendous interim advances in treating advanced HL.

The take-home message from all of this is that Rx information DOES matter and one could make a case for it mattering as much or more than any other single snippet of information about any given medical history.

Which is what I am about to do.

 

Why is the identity of pharmaceuticals taken by insurance applicants so significant?

Probably 95%+ of the time when someone goes to see their physician with a medical complaint, they come away with a prescription for one or several medications. One could even argue there is an expectation of this on the part of most patients, especially those over 50.

Therefore, one thing that we should ask about on all occasions, and expect an affirmative response nearly every time, is “what medication were you given,” or something to that effect.

Will the applicant know?

I hope so, unless there is a cognitive issue present…or he is trying to intentionally not disclose information!

Years of working with teleunderwriting as well as Rx profiling (a resource we have in the USA for underwriters) has taught me that the vast majority of people know what they are taking, almost always by name. Moreover, the likelihood that they will know increases as they are positioned further up the socioeconomic “food chain” in terms of years of education and job status. This matters because the larger policies – and thus greater risks – are usually sold to people who are more disposed than the average applicant to know their medical circumstances, including all of their medications, very well indeed.

To know, you have to ask…and persevere until you get all of the information, by asking after they cite one drug if that is the only drug, and so on. Give them every chance to tell you the full content of their personal pharmacopeia, especially if they are age 50 or over.

You will get a hodgepodge many times.

Misspelled drug names, 80% proprietary names (while generic names are easier to track down, especially across borders) and so on will be prevalent.

But, what you will get is priceless when you’re trying to make that core decision in teleunderwriting: can I take action with what I have or must I shag down medical records and/or other additional requirements?

All drugs have a finite list of reasons for which they are prescribed. That list consists of two elements: uses that have been approved by the national jurisdiction entity (in the USA, the Food and Drug Administration, or FDA) and additional uses that have not been approved (which we usually call “off-label” uses, even though that word has an unpleasant connotation in the pharmaceutical industry!).

The “approved” uses (called “indications”) can be found in whatever drug compendium prevails in a given country. The “off-label” uses are another matter. We haven’t found one resource yet that lists anywhere near all of them, keeping in mind that new ones come on the scene on almost a daily basis!

What confers “off-label” use status on a given medication?

The fact that physicians – hopefully based on credible scientific studies showing that the drug does indeed work for the intended disease or condition – prescribe the drug for this disease or condition even though it has yet to be officially sanctioned for this specific use.

Is this a legal problem for physicians?

No…as long as the data on which they relied for their decision is valid and other docs are doing it as well!

Our problem is discovering, for any given drug, whether or not it has prevalent off-label uses and what those uses are. Why? So we can adequately link the drug to all of the other information given on the drilldown questions asked of the applicant.

This, by the way, is one reason our company came out with something that has never existed before: the Underwriting Guide to Rx. One of the many things it does is provide the vast majority of known “off-label” uses, based on our comprehensive and ongoing review of most major medical journals relevant to underwriting.

Once the underwriter knows all of the potential uses of a drug and correlates this with the medical history, the process of risk analysis can proceed based on the rest of the teleinterview drilldown information.

 

What are the aspects of drugs that are most important in teleunderwriting?

Let me observe at the onset of this section that I did a major white paper on Rx profiling for the industry some months ago. This paper was written for US companies because it involves the value of Rx profiling, an asset we can access in day-to-day underwriting.

This paper is posted at Insureintell.com.

Unfortunately, it seems unlikely that anything akin to this can be created outside the US. The reason for this is that most countries have national health care and therefore these records come under governmental control. Governments do not work “for profit” (although sometimes you have to wonder about this assumption!) and thus it would be difficult to convince them to give us access to this kind of person-specific Rx information.

This said, I think every underwriter in the world should read this white paper.

Why?

Because by explaining why information provided by Rx profiles has value, it actually explains why Rx information from any source has value!

Which means you do not have to do formal Rx profiling as many – but not all (as yet) – US companies do in order to gain a HUGE advantage from understanding how medication information can impact insurability!

You can get a lot of what you need from the teleinterview drilldown and then apply that on the same basis as you would what you’d find on the Rx profile.

And I refer here to medication information disclosed from shrewd questioning on a teleinterview, including on every impairment drilldown.

Here, briefly, are some of the things that matter and should be looked at for each drug that the proposed insured is taking…or has taken certainly within the last 1-5 years (depending to some extent on the nature of the drug.

 

1. Where does this particular drug fit into the “pecking order” of drugs prescribed for the impairment in question?

Is it a so-called “first line” drug that is usually used first and typically is effective in the easiest to treat (and thus, most often, BEST) cases of the impairment…or, is it a “second line” or even “third line” drug?

When “first line” drugs either don’t work or cause unacceptable complications, the doctors will either use another “first line” drug or move to a “second line” drug. Then, if that drug also has issues, on to another “second line” or even a “third line” drug…because most doctors follow the basic Rx paradigms set up in their country (especially primary care physicians).

Once we get to “third line” drugs, we are usually talking about drugs that are more toxic (have more side effects, sometimes life-threatening in nature) and thus are reserved for the hardest cases to treat. We can use this insight when deciding whether or not to order medical records.

In fact, there are also a few “compassionate use only” drugs used in the very worst cases, when all else fails and the options left are very risky (or there aren’t any options left). One example in the US is felbamate, an anti-seizure medication that can induce potentially-fatal aplastic anemia. It is rarely used…and when it is, we know right away that we have a WORST CASE and must get medical records.

 

2. Has there been a change in drugs?

Few things are more revealing than when a physician changes the drugs given for any disorder.

The first question is: was this due to side effects (including the possibility that the patient was not being compliant by not taking the drug as prescribed) or was it because the drug wasn’t working? This is a question that can be directly resolved on telephone interviews when an applicant says his doctor changed his medication three months ago.

If the change is to a stronger (“second line” or higher) drug, or if a second drug is added to the first one already being taken, this is usually a reason for concern. In many – but by no means all – such cases, one would pursue medical records. Distinguishing those where it is needed vs. where it is not essential is one of the things we do on our Rx Guide, with our “cautions” and “red flags.”

And then, vice versa, when a stronger drug is replaced with a milder one (which may signal improvement in the patient’s condition).

The pattern of medication use in chronic disease, going back as long as five or more years prior to the application, can be informative. On occasion, it will be desirable to ask about the history beyond just “has your doctor ever changed your medication” and then asking, if YES, asking if there were Rx changes once or more often prior to the most recent medication switch or adjustment.

 

3. What is the dose and how often is it taken?

Every drug has a dosage and 99% of drugs are taken at least once per day (unless they are administered on a one-time basis for acute reasons).

Most drugs come in a range of doses. The lower doses may be used to start the patient on an ongoing basis (this is common with some psychiatric drugs) or they may given for another reason (body weight of the patient, milder degree of impairment, and so on). The same is true of the higher doses.

Sometimes, however, there is a significant message to be discovered based on dosage. For example, there are psychiatric drugs where low doses mean one type of impairment whereas high doses mean a very different – and more significant – condition is present. The same can be true of other classes of drugs as well.

Sometimes, too, primary care doctors will under-prescribe. This is not uncommon in primary care where drugs for depression or anxiety are prescribed.

The physician will prescribe half of the usual starting or minimum dose. What happens often is that this means the patient gets some side- effects and spends money…for no clinical benefit! Such inappropriately low doses are often called “homeopathic” doses and can be spotted by persons informed about pharmacology.

Along with dose and times taken comes the matter of how the drug is delivered.

Many drugs come in both pill and injection forms. Some come in as many as 7 different modes of delivery (the one I know with 7 is nitroglycerin).

In many cases, the pill form signals a less severe condition than the injected form.

A good example of where the pill form is worse is glaucoma. The BEST cases are treated with eye drops; the worst with oral medications.

 

4. Is the doctor prescribing “combination drugs”?

I use the term “combination drug” here in the context of two (rarely, more) distinct medical ingredients in one pill. This is common with drugs for hypertension and now with hypolipidemic (cholesterol and triglycerides lowering) drugs as well.

Use of a combination drug may mean a different impairment from what we thought. It may also be a clue to the impairment being less favorable than it would have been if one drug alone was given.

 

5. Is the insured compliant with the prescription?

Another word for this is adherence…as in, does the patient adhere to the schedule he was given by the doctor (and that is likely cited on the pill bottle!) for how many times a day, and if more than once, at what times, the drug should be taken?

Poor drug adherence is such a major issue that we are doing an entire continuing education course in this subject in 2008.

True, the best way to know this is to have access to Rx profiling, where the information is usually presented to you instantaneously as part of the whole electronic profile on the proposed insured. However, you can also ask about this subtly on the drilldown, saying something like “how many times per week do you take your medication…” I have seen this done successfully!

 

The Medication Not Enough People Talk About: Alternative and Complementary Herbs and Other Digestibles

I am absolutely flummoxed by lack of appreciation by American underwriters regarding the importance of knowing the facts when insureds use these kinds of remedies, whether herbs or massage therapy or whatever it happens to be.

Perhaps they just don’t understand how many times there is a significant correlation between a chosen non-traditional remedy and the nature and extent of a potentially-significant impairment…one that may not even be mentioned otherwise!

Take for example the hawthorn root.

Ever heard of this?

It’s an herb sold in pill form in most health food stores.

If you read the bottle, it will be quite vague…at least in America where herb peddlers are not allowed to make “unproven claims” about their products.

However, all this aside, did you know that hawthorn is a widely recognized (even by clinical cardiologists) remedy for early/mild congestive heart failure? That some say it is better than digitalis and other toxic drugs? That anyone taking hawthorn MUST be questioned further unless you want someone deceptive to succeed in getting coverage you would otherwise likely decline?

Hawthorn is far from alone in this regard.

Shark cartilage, which is not an herb and is generally referred to in the broad nonspecific category called “digestibles” (which, of course, includes herbs), is thought by many to have cancer treatment potential.

No, really…and so much so that the US National Institutes of Health’s division that studies alternative remedies is doing a specific medical study to see if shark cartilage does, indeed, have any value here. The same is being done elsewhere with mistletoe…and heaven only knows how many other of these kinds of non-traditional remedies that are usually taken like conventional medications (that is, in pill form).

If a 60 year old man is taking gingko biloba, one of the most widely used herbs, is he doing it solely as a prophylaxis (that is, to lessen his risk of certain diseases) or is he doing it because he already is experiencing memory loss or strange cramps in his legs? The former complaint, of course, may be early Alzheimer dementia and the latter sounds a bit like somewhat advanced peripheral arterial disease.

Does this mean that every older person on ginkgo biloba is a bad risk?

Hardly…prevention still remains the #1 use at all ages.

But what if there are other symptoms, or a doctor mentions a specific test that might be done because of suspicion of AD or PAD? In either of these situations, you would definitely insist on more information before accepting the risk!

There is little point in going on with example after example.

The best course of action is for your company to ROUTINELY ask about alternative and complementary medicine and then acquire sufficient information so underwriters know at least the most commonly-taken types that are possible RED FLAGS.

We did a continuing education course on this subject last year which gets at this to some extent. What is needed is an on-line resource akin to our Rx Guide, covering these remedies and others taken “over the counter” at the person’s discretion.

However, when I ask American chief underwriters if they would value such a resource, the response is usually ambivalence.

Too bad, since this is a major area that is growing several times FASTER than conventional medicine and that is most often sought out by more affluent individuals. Individuals who are – one hastens to add – sicker than their peers with the same impairment who choose to use exclusively conventional Rx.

 

Summation

No other single bit of routinely gathered information on a teleinterview drilldown can match knowing the medication, especially when you know as much as there is to know about it in context (dose, times taken per day, delivery system, how long used, ever changed and so on…).

If you underwrite business in the United States, you can use Rx profiling. One would have to think that, given its value in relation to its cost, this will become a routine screening requirement on all applications in the near future.

If you’re not based here, or if you just don’t want to invest in profiling, then you can still accomplish a great deal by asking properly about Rx information routinely on EVERY impairment…on EVERY drilldown.

 

 

DISCLAIMER This essay was written for informational purposes only. Hank George and Hank George, Inc. do not recommend or endorse any specific business practice or procedure discussed herein. All business considerations concerning matters covered herein should undergo proper and sufficient scrutiny by appropriate management personnel of the companies involved prior to implementation on any basis. © 2009-10 Hank George, Inc.