View
30
Download
0
Category
Preview:
DESCRIPTION
The Economic Stakes Involved in Genetic Testing for Insurance Companies. Dr. Christoph Nabholz CDBI Seminar on predictivity, genetic tests and insurance Strasbourg, 3/4 December 2007. Health. Life. G Medex. - PowerPoint PPT Presentation
Citation preview
The Economic Stakes Involved in Genetic Testing for Insurance Companies
Dr. Christoph NabholzCDBI Seminar on predictivity, genetic tests and insuranceStrasbourg, 3/4 December 2007
Page 2
Private insurance is complementary to social insurance and is tailored to individual need
Social Private
Government
Compulsory
Individual
Free Choice
Employer
Compulsory
Group
Health
LifeHealt
hLifeHealth Life
Life
DI
CI
MedexG Medex G LifeHealth Care
Social Care
No CompleteSimplified
G DI
Pro
du
ct
UW
Wh
o
Note: UW = Underwriting; DI = Disability Insurance; CI = Critical Illness
Page 3
Underwriting reduces the risk of anti-selection and keeps the system in balance
Page 4
Because of underwriting, the vast majority of applicants can be accepted at standard rates
Page 5
Private life insurance is far cheaper today than in previous decades
Page 6
Information considered in the underwriting process is diverse
Medical risk factors
– Age, gender, build, medical history, family
history, body-fluid tests
Non-medical risk factors
– Financial: occupation, income, sum assured, insurable interest
– Behaviour: sports, travel, alcohol, drugs,
fitness
Page 7
Few risk factors exist to assess cancer risk and the new ones investigated are of a genetic nature
Family history Predictive genetic testSmoker statusBody mass index
Disease-free
Symptomatic
Tumour markers Expression profile Past history of cancer Diagnostic genetic test
Traditional risk factorsFuture potential risk factors
Page 8
In the USA premature mortality due to genetic predisposition is considerable
McGinnis et al.Health Affairs2002; 21: 78-93
Page 9
A key challenge for life insurers in the future is whether new laws restrict use of traditional risk factors
The issue of whether life insurers have access to genetic data is further complicated by the argument that all diseases are influenced by our genetic make-up
Could any medical test result that relates to a possible future health outcome reveal information of a genetic nature?
This question may create issues for life insurers about the overall medical risk assessment process, including challenges over the use of family history information
Page 10
Life insurers have a long tradition of requesting, and responsibly using, family history information
The life insurance industry has a good track record of handling medical and other personal data with great care and professionalism
For over 150 years life insurers have asked questions about the occurrence of disease in close family members 1848 Canada Life Assurance Company’s medical exam form asks:
“Has he, in your opinion, any hereditary predisposition to any disease; and if so, to what?“Can you state anything respecting the health of his parents or relatives, with which the Directors of this Company should be made acquainted? If so, what?”
2006 medical examination form of the Swiss Insurance Association “Has any one of your parents, brothers, sisters, or grandparents, before age 55, developed neurological disturbances, heart diseases, stroke, diabetes mellitus, cancer or hereditary diseases? Which disease(s) and how many had developed the disease?”
CaplanCMAJ 2003; 169: 1331
Canada Life Assurance Company
Page 11
Insurance-based family history data are statistically sound and fulfil strict data protection standards
Today's family history question fulfils privacy requirements and is different from a more systematic family anamnesis used by the genetic consultant in that:
– it is less systematic e.g. does not extend to cousins
– the direct relation to the applicant is not revealed, but the group is large enough that the information can be considered non-identifiable
The data used in underwriting is statistically relevant for the diseases in question
Written consent is given by the applicant
Page 12
Family history is a risk factor for most common complex diseases
Am J Prev MedFeb 2003
Disease Relative Risk
Heart disease 2.0 – 5.4
Breast cancer 2.1 – 3.9
Colorectal cancer 1.7 – 4.9
Prostate cancer 3.2 – 11.0
Melanoma 2.7 – 4.3
Type II diabetes 2.4 – 4.0
Osteoporosis 2.0 – 2.4
Asthma 3.0 – 7.0
Page 13
Rating guidelines for underwriting family history of breast and ovarian cancer
Risk classification Life rating
Male applicant Std
Female applicant:
1 first degree relative only with breast and/or ovarian cancer
Std
2 first degree relatives with breast and/or ovarian cancer, both with diagnosis > age 50 Std
> 2 first degree relatives with breast and/or ovarian cancer, at least one of which diagnosed < age 50:
Following prophylactic bilateral mastectomies:
Years since surgery:
< 1 +50 EM
> 1 Std
No prophylactic mastectomy +75 EMNote: Std = Standard and EM = Extra Mortality
Page 14
Family history provides a proxy for genetic risk and is key to life insurance underwriting
Family history is a common clinical marker used as a proxy for genetic risk
The probability of contracting breast cancer increases with a positive family history and even more with BRCA mutations associated with higher incidence of disease
Ponder; Science; 1997; 278: 1050
Page 15
The current growth rate of clinical genetic testing in Europe and the USA is about 30% p.a.
Ibarreta et al.EC Sep 2003EUR 20977 EN
In 2002 in Europe 700,000 genetic tests were performed in clinical practice
1997 activity was taken as baseline index of 100%
Estimated % growth in genetic testing activity since 1997
Page 16
Growth rate of disclosed genetic test results to life insurers in the UK and Australia is about 35% p.a.
ABI Code of Practice on Genetic Testing
Compliance Reports 1999 to 2005
Total of 3421 test disclosed in 6 years
~0.05% of all applications in 2004
IFSA Genetic Testing Survey Reports
2001 to 2005
Total of 667 tests disclosed in 4 years
~0.06% of all applications in 2004
# g
eneti
c te
st r
esu
lts
dis
close
d p
.a. UK – ABI survey Australia – IFSA survey
Page 17
In the UK about 4% of the genetic tests done in clinical practice are disclosed to life insurers
ConditionGene
ABI2004
GTN2003 %
Haemochromatosis HFE 139 2854 4.9
Huntington's Disease HD 127 1239 10.2
Thrombophilia (Factor V / Prothrombin)
F5, F2 106 2805 3.8
Breast/Ovarian Cancer (BRCA1/2) BRCA1, BRCA2 95 3141 3.0
Myotonic Dystrophy (MD) DMPK 70 1244 6.2
Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
MSH2, MLH1, PMS1, PMS2, MSH6, TFGBR2, MLH3
35 1229 2.7
Familial Adenomatous Polyposis (FAP) APC 28 471 5.9
Alpha 1 Antitrypsin Deficiency PI 22 75 29.3
Charcot Marie Tooth disease PMP22 21 2461 0.9
Polycystic Kidney Disease (PKD) PKD1, PKD2, PKD3 19 45 42.2
Multiple Endocrine Neoplasia (MEN) RET 13 357 3.6
Total 677 15’921 4.3
Page 18
About 70% of disclosed results to life insurers in the UK are predictive genetic tests
Condition Total Diagnostic
Predictive
Don't know
Haemochromatosis 139 35 79 25
Huntington's Disease 127 2 117 8
Thrombophilia (Factor V Leiden / Prothrombin) 106 41 46 19
Breast/Ovarian Cancer (BRCA1/2) 95 7 81 7
Myotonic Dystrophy (MD) 70 7 54 9
Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
35 0 29 6
Familial Adenomatous Polyposis (FAP) 28 2 22 4
Alpha 1 Antitrypsin Deficiency 22 4 12 6
Charcot Marie Tooth disease 21 10 8 3
Polycystic Kidney Disease (PKD) 19 0 17 2
Multiple Endocrine Neoplasia (MEN) 13 2 10 1
Total 675 110 475 90
ABI Code of Practice on Genetic Testing Compliance Reports 2004 100% 16.3% 70.4% 13.3%
Page 19
In the UK about 75% of the disclosed predictive genetic test results are “negative”
Condition Predictive
Adverse+
Normal-
Ambiguous
Huntington's Disease 117 25 91 1
Breast/Ovarian Cancer (BRCA1/2) 79 21 53 5
Myotonic Dystrophy (MD) 54 9 44 1
Familial Adenomatous Polyposis (FAP)
22 1 21 0
Multiple Endocrine Neoplasia (MEN) 10 6 4 0
Total 282 62 213 7
ABI Code of Practice on Genetic Testing Compliance Reports 2004 100% 22% 75.5% 2.5%
Note:
In the UK the only genetic test allowed to rate is for Huntington’s disease
Negative genetic test results may be used in favour of the applicant to wave family history ratings
Page 20
Summary of exposure of genetic information to life insurers
A significant part of today's health determinants is due to genetic pre-disposition
– the clinical genetic testing arena is growing at about 30% p.a.
In the UK only a small percentage of genetic tests used in clinical practice are disclosed to private insurers
– 70% of disclosed results are pre-symptomatic tests and 75% are “negative”
Family history is a key life insurance risk factor which allows to reduce anti-selection due to non-disclosure of genetic test results
– statistical evidence exists for family history ratings
Page 21
Conclusions
The freedom to price and underwrite according to the risk presented is the fairest way to cover the maximum number of people at a competitive low price
Concern for insurers is information asymmetry which could lead to potential anti-selection
– the cost of which must be cross-subsidised by the pool which may cause premiums to go up, or products to be withdrawn
Life insurers want fair access to risk relevant information but do not require applicants to undergo genetic testing
– diagnostic genetic tests confirm present disease and therefore should be treated different from predictive tests
– genetic test results will only be taken into account when their reliability and relevance is established
The Economic Stakes Involved in Genetic Testing for Insurance Companies
Dr. Christoph NabholzCDBI Seminar on predictivity, genetic tests and insuranceStrasbourg, 3/4 December 2007
Recommended