Transcript Disability past present and future.

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,
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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
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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
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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
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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
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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
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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
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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