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Dr Dominique Stott. DISABILITY PAST PRESENT AND FUTURE. Under discussion General issues Defining disability Disability vs. impairment Present issues Anticipated problems Conclusions. In general.. Thanks to: RGA and Hannover-re Anecdotal evidence from various sources including co-workers All references available freely available and in the public domain All insurance definitions for disability intended: TD, OD, OOD, PHI, LCB and LPB Not a statistical analysis Paucity of available data for insurance purposes Most relates to death - easy to quantify! Disability information far more difficult What is ‘Disability’? Dimensions: pain, discomfort, physical dysfunction, emotional distress, reduced independence ADL’s, loss of dignity What is true disability and how do we measure it? True disability-what is it when so many people work with ‘impairments’? Is it a state of mind/personality type rather than a physical or mental state of body? Defining disability Why define disability Different definitions for different study groups: insurance, medical research, government studies, disabled groups, etc. Original ICIDH (WHO): Disease>impairment>disability>handicap ICIDH-2 (WHO 2001): Inability or restriction to perform any normal human activity – NB not work related definition! AMA Guide 5th ed: an alteration of an individual's capacity to meet personal, social, or occupational demands because of an impairment SSA: inability to engage in any substantial, gainful activity by reason of any medically determinable physical or mental impairment which can result in death or last not less than 12 months (TD definition) WC: reduction in wage earning capacity due to injury, illness or occupational disease occurring during employment. ADA (Americans with Disabilities Act): a physical or mental impairment that substantially limits one or more of the major life activities of such individual; or a record of such impairment; or being regarded as having such an impairment. Virtually everyone would therefore at some time have been disabled! Definition changes as ADA cases are tried in court! However all agree on 12 months as permanent Insurance context Disability: Health impairment leading to inability to perform one’s named occupation. Not quantifiable Subjective evaluation Variable outcomes of assessment Should assume treatment or rehabilitation Permanent health status but time to achieve this variable – unique individual health recovery rate Incidence Health Survey England HSE 2001: All ages, races, income groups 18% - 1 or more of 5 types disabilities 5% serious disability Locomotor – musculoskeletal/CTD Strong relationship with SE class especially N/NE England Worldwide: 5.2% world population: 7.7% developed nations and 4.5% undeveloped (accuracy?) Incidence RSA Integrated National Disability Strategy White Paper 1997: Probably ‘TD’ not ‘OD’ Across all ages and races and income groups 5% local population disabled 1995 MRC continue to study disability but do not have accurate figures Causes of claim: Hannover-re % claims paid For the years 2005/2006/2007- Musculoskeletal the largest number of claims Apart from 2005 also the largest amounts of claims paid Always in the top 6 causes of claim South Africa: Number of Claims by Cause Cause of Disability 1994 to 1998 1998 to 2001 2002 to 2005 Musculoskeletal / Back / Violence 32.80% 28.30% 26.30% Neurological 9.20% 12.10% 6.10% Psychiatric 8.80% 8.90% 8.00% Cardiac/Circulatory 15.60% 14.60% 14.40% Sensory 6.60% 6.10% 5.60% Respiratory 7.90% 8.70% 9.50% Cancer 5.80% 6.90% 8.80% HIV/AIDS 0.50% 4.50% 7.80% Endocrine 3.30% 3.00% 3.70% GIT/Genito-urinary 2.80% 2.90% 2.90% Infection 4.60% 1.10% 1.30% Other 2.20% 3.00% 5.60% Total 100% 100% 100% Although musculoskeletal/etc largest number of claims, no conclusive evidence that rehabilitation actually helps This is the group in which rehabilitation is the most appropriate Rehabilitation 30 years ago limited to mechanical aids – now technological advances allow sight, speech, movement, etc. Significance in insurance Even those unable to perform ADL’s not necessarily ‘occupationally disabled’ May be significantly impaired but not occupationally disabled e.g. quadriplegic May be mildly impaired but significantly disabled e.g. concert pianist with digital nerve injury Needed to cater for this in an insurance environment Impairment ratings Allows for ‘impaired vs. disabled’ concepts Semi-quantifiable Not as subjective as disability Various systems available worldwide Ratings still variable from one system to another Related to ability to perform ADL’s not workrelated tasks Impairment definitions ICIDH-2(WHO) loss or abnormality of psychological, physiological or anatomical structure or function SSA an impairment that results from anatomical, physiological or psychological abnormalities which can be shown by medically acceptable clinical and lab diagnoses- specifically not symptoms AMA 5th ed: alteration of an individual’s health status; a deviation from normal in a body part or organ system/functioning This was used to develop the benefit for impairment type benefits Many other impairment type benefits now available but the principle is the same Relies on ability to perform ADL’s but no relation to occupation AMA Guide 5th ed. Advantages: Attempt to semi-quantify the unquantifiable All functional units of body covered Ranges of impairment rating Can be combined to give overall WPI Concept of WPI and MMI Able to extrapolate to other product types Can be used to determine ability to work indirectly AMA Guide 5th ed. Disadvantages: Only ADL related Inconsistencies in interpretation Range of value ratings which lead to more inconsistencies Should relate to: - actual loss of functionality - loss of quality of life to be fair to client’s alteration in life circumstances Client perspective: how loss of function or body part has led to inability to perform occupation Compared to Insurance perspective: what remaining function is there that would allow the person to continue to work Present disability issues We have come a long way in the last 10 years Beginning to address issues of: Data collection Improved medical professional input by training Utilising different professional inputs Watch for future trends…. Future burden of disease/ disability Not an exhaustive list! Communicable: HIV, co-infections, CHC Non-communicable: obesity, lifestyle, genetic Environmental: toxins, radiation Unable to rate individually for Violence and trauma related Communicable 25 people cross national borders every second 1 billion journeys made internationally annually World cup soccer: 400000 visitors over 43 days, 32 teams internationally Many will cause disabling consequences Epidemic and Pandemic alert and Response EPR Anthrax - Avian influenza - Crimean-Congo haemorrhagic fever (CCHF) - Dengue/dengue haemorrhagic fever - Ebola haemorrhagic fever - Hepatitis - Influenza - Lassa fever - Marburg haemorrhagic fever - Meningococcal disease - Plague - Rift Valley fever - Severe Acute Respiratory Syndrome (SARS) - Smallpox - Tularaemia -Yellow fever Dr Brundtland WHO 2003 “SARS is a warning,” said Dr Brundtland. “SARS pushed even the most advanced public health systems to the breaking point. Those protections held, but just barely. Next time, we may not be so lucky. We have an opportunity now, and we see the need clearly, to rebuild our public health protections. They will be needed for the next global outbreak, if it is SARS or another new infection.” HIV 18.8% adult prevalence rate RSA 2005 with 571000 new HIV infections in that year MRC report: HIV will more than double the burden of premature mortality and morbidity by 2010. HAART and ARV’s : Improved survival of HIV + gives increased burden of non-fatal outcomes and more disabled people. Causes of HIV disability: THE GREAT PRETENDER HIV (cont’d) Causes of disability: Respiratory including TB Neurological Dermatological Gastrointestinal Psychiatric Metabolic and muscle wasting. NB fatigue and peripheral neuropathy! HIV/TB combination Infectious Diseases Society of America (2007): Worldwide (WHO 3/2007): 2 billion infected TB 8 million contract TB annually (not active TB) 2 million die from TB annually 40 million HIV+ and 30% of these have TB Sub-Saharan Africa: 80% TB are HIV + South Africa: 58% new adult TB are HIV + TB leading cause of disability and death for HIV + MDRTB Definition: resistant to at least Rifampicin and Isoniazide 1.7% TB in 2000-2003 but 9% in 2003-2006 9.9% MTB strains resistant to at least one drug in 35 countries or regions Non compliance/malabsorption of drugs Often from HIV + sources in community Not only in HIV + also HIV 400000 worldwide MDRTB+ MDR-TB (continued) Treatment of MDR-TB associated with prolonged illness and disability Second-line TB drugs have a greater incidence of adverse reactions, which increases the morbidity Botswana health report: 1/2008 100 MDRTB 2 XDRTB Tugela ferry: 2005 WHO 544 TB+ 221 MDRTB 53 XDRTB XDRTB Resistant to MDR drugs plus fluoroquinolones and one injectable drug Problems with treatment: Isolation Expensive Default on treatment Not a true disability issue as mortality so high Hepatitis CHC Anouk et al Infect Med 2005: CHC. Hepatitis C is the new epidemic in USA. 170 million people worldwide Leading indication for transplantation Mostly accompany blood sources or drug abuse Disability due to carcinoma and cirrhosis Vaccines only for A and B Treatment: only effective in 50% of cases (rest become CHC) side-effects, prolonged, not suited to all patients Non-communicable/ lifestyle Due to increased complexities of society and lifestyle issues: Nutrition, physical activity and obesity issues Drug related issues Genetic disorders Smoking and psychiatric not discussed here Obesity and lifestyle ‘Sloth and gluttony’ Prof Harry Seftel Fastest growing epidemic in EU 10-20% of the population have BMI over 40 Next generation: childhood obesity and DM – these are our future clients! DM childhood has 100x risk of DM than that of normal weight child Long term sequelae: DM, CVD, stroke, arthritis, cancer. Eurodiet study 2001 complications associated with obesity account for 5-10% health costs in EU - more than tobacco use Men 1998 Obesity stats in SA Women 70 Percentage 60 50 40 30 20 10 0 Underweight Normal weight MRC: Chronic Diseases of Lifestyle in South Africa: 1995 - 2002 Overweight Obese Other nutrition Folate deficiency and Alzheimer's disease. Increased intake of red meat and processed meat and colorectal cancer. Salt and preservatives increased gastric cancer. Many more examples too numerous to mention. Recreational pharmaceuticals Prevalence insurance market – present age group is our future market! Cocaine incidence increasing worldwide: Spain highest user in the world 3% of the population, with 100 tonnes seized in 2005/6! Also OTC e.g. Stopane and slimming tablets Disability: long term effects and associated disorders Other mental disorders: 2/3 cocaine addicted have associated mental disorders (NIDA USA) Any lifetime mental disorder has a 15% incidence of drug abuse. Marijuana Tranquilising drug Cancers - oral cavity, pharynx, and oesophagus. Respiratory system - damaged by smoking. Psychological effects - panic reactions, psychosis, amotivational syndrome (diminished drive, ambition, motivation). Impaired educational attainment and significant adjustment problems. Ecstasy MDMA Serotonin system - Johns Hopkins/NIMH study: other cognitive functions besides memory, such as the ability to reason verbally or sustain attention. Four days of exposure to the drug caused damage that persisted six to seven years later. Journal of Neuroscience : Long-lasting damage to brain areas that are critical for thought and memory Cocaine Smoked, snorted, IV Disabling consequences: Psychiatric - Irritability, Mood disturbances , Restlessness, Paranoia, Auditory hallucinations CNS - strokes, seizures Cardiac - ventricular fibrillation / CMP OTC Tablet form but who knows! Opioids : Oxycodone (OxyContin®) CNS Depressants: Benzodiazepines Diazepam (Valium®) Chlordiazepoxide hydrochloride (Librium®) Alprazolam (Xanor®) Stimulants : Dextroamphetamine (Dexedrine®) Methylphenidate (Ritalin®) Genetic disorders Human Genome Project Information: Mostly multifactorial Clear evidence for: psychiatric including alcoholism; metabolic; cardiac; neurological Genetic discrimination and bioethics Direct-to-consumer testing problems for insurance industry Environmental problems Related to industrialisation: decreasing in the first world industrialised nations but increasing in third world economies SO2 and NO2: respiratory and visual problems decreased pH in the atmosphere. Heavy metals (fossil fuels) : cadmium, nickel, lead, arsenic - cancer. Ozone and global warming: radiation-related diseases e.g. Dermatological pathology, visual disorders. Fine particle matter: RS and CVS disease. Radiation: various sources e.g. cell phones, power lines Violence/trauma Average 20 disabling accidents per day in RSA 90% causes are due to breaking traffic law in particular speeding For every fatal accident there are victims disabled Not much chance of underwriting this out the equation! ‘Plus ça change, plus c’est la même chose’ How can we learn from the past? The problems remain the same! Malingering, entitlement, belief in disability, etc. Three most important aspects: Future-proof our definitions e.g. rehabilitation Underwrite differently e.g. occupation, drugs Assess utilising all resources optimally: medical science and treatment, rehabilitation advances, new occupational training Claims assessment LOA disability guides e.g. psychiatric, spinal, respiratory Neurological disorders e.g. neuropsychological assessments Others: CFS, mental disorders Medical advances: medication, surgery, rehabilitation techniques In conclusion Impairment benefits provide a form of solution to some of the problems of disability benefits Locomotor problems are the biggest cause of claim but rehabilitation is seldom the solution Diseases to watch out for in future may be already evident – are we doing enough about them? Abraham Lincoln: its not the years in your life but life in your years. Thank you