Keeping pace

Medical research is advancing on a number of fronts, which means the expectations of how a person might be affected by a particular disease or condition today might be considerably different to what they were a few years ago. Obviously, this has a significant impact on the income protection (IP) industry and it is vital for insurers to have knowledge of the range of effects that can arise from a particular condition, whether as applicants for insurance cover in the underwriting arena, or as claimants for IP benefits.

A new report, Trends In Health And Disability 2002, focuses on those medical areas most relevant to common claims such as mental health, musculo-skeletal disorders ' including chronic back pain, upper limb disorders and inappropriate pain ' chronic fatigue syndrome and cardiology.

It highlights the advances being made in the treatment of a number of conditions, particularly heart disease, but emphasises the importance of psychological factors in determining long-term disability, whatever the original underlying cause might be. It also comments on the expectations being made in the field of genetic testing and the fact that for all advances, the expectations of what might emerge from this are at present ahead of the ability to deliver.

The report also highlights how the issues identified are also important ' not just for the insurance industry ' but that they are now being recognised by those developing both health service and social security policy.

Initiatives such as NHS Plus, Health Action Zones as well as job retention and rehabilitation pilots are highlighted as actions being taken to address the important issues identified.

With musculo-skeletal disorders, advances relate more to increased understanding of the nature of chronic, painful conditions, including back and upper limb pain rather than any particular technical breakthrough.

For example, there is an increasing realisation of the need for people to remain active and for clinicians to intervene early in the process to ensure that optimum recovery and rehabilitation is achieved. This is also true for those conditions where no specific underlying disease process has been identified.

For work-related claims this means employers working with insurers to help employees suffering from this type of pain, during the first stages of absence.

It has been shown that early intervention, including good ergonomic assessment and modification of working practices and workstations, is one of the most critical factors in reducing the time off work in these types of cases.

New breed of illness

It is becoming increasingly recognised that many people are attending their doctor with symptoms which cannot be explained by traditional models of disease. The problem of medically unexplained or functional illness is therefore a large one which is likely to get bigger. Social factors are more likely to influence the trends in prevalence, presentation and costs than medical developments are. This is an important message for both health services and insurers. For those people with established disability an increasing need for rehabilitative treatment facilities is identified.

The diagnosis of heart attack has been affected by the discovery of a new super-sensitive biochemical marker of heart muscle damage know as Troponin T. This means a diagnosis of heart attack is now possible, where episodes of chest pain might previously have remained undiagnosed.

Moreover, this has important implications since the life expectancy of such people may not be impaired in the way that is traditionally the case for people who have had heart attacks.

Matters of the heart

The overall prognosis of people with coronary heart disease has been affected by the more widespread use of the lipid lowering drugs know as 'statins.' The greater attention to detail in control of blood sugar, enhanced by statins, means that the prognosis for people with diabetes mellitus can be much better than was previously the case. This has a significant impact for insurers reviewing their underwriting policies over the next year or so.

Reports have also identified improvements in surgical treatment of established coronary artery disease, which should lead us to expect an increasing trend in people being able to return to and remain in work.

For example, the increasing use of percutaneous coronary intervention (coronary angioplasty) should mean uncontrolled ischaemic chest pain will become less common. This is important information for benefits claims managers, in forming their expectations on individual cases.

Improvements in the diagnosis and treatment of heart failure, including drug therapy and new pacemaker techniques, have also taken place. The prognosis for many people with heart failure has consequently improved which will enable some people to remain at work where this would not have been possible in the past. Improvement in the diagnosis of a number of conditions including prostate cancer, cerebrovascular disease, multiple sclerosis and brain tumours is highlighted. The development of new imaging techniques has been particularly important in bringing these about.

The importance of depression in contributing to overall disability in a number of general medical disorders is noticeable.

Within the mental health sector, the developments with implications for the insurance industry are not so much in the field of the treatment of serious mental health problems. The treatment of severe depression, for example, has not changed significantly since the first discovery of anti-depressant drugs. While some important developments have taken place in the understanding of the physical basis for some serious mental health problems, the significant advances are much more to do with the understanding of the importance of psychological factors in determining levels of disability in relation to a wide variety of medical conditions. The importance of the role of psychological treatment in the management of both anxiety and depression has become apparent over the last few years. Cognitive behaviour therapy has become recognised as having a central role, both in these disorders, but also in the treatment of a variety of other conditions.

The fact that there have been few advances in the treatment of depression represents a challenge, not only in the field of mental health, but across all areas discussed in this article.

For example, a key trend is the importance of symptoms which fall short of producing a definite depressive illness, but which may well have an influence on overall disability and recovery rates. Its impact on the fields of cardiology and general medicine has been particularly emphasised in all commissioned reports.

This presents a great challenge in being able to identify those claimants where depression may be having a significant impact at an early stage of their incapacity. There is a part for the insurers to play in being able, at this early stage, to influence their treatment, since it is clear that these issues are not always being adequately addressed within the constraint of primary care. It is clear that policymakers in the public sector also recognise the need to influence this situation and become more effective in being able to intervene early in the development of any disability.

There is clearly, however, a lot of work to be done to turn the various government initiatives into a reality. The overriding theme for the IP industry is twofold:

l The importance of psychological factors in determining long-term disability and in particular in determining which people are likely to have long periods of sickness absence while other people with similar underlying physical impairments may be able to return quickly to work.

l The importance to early intervention to minimise the risk of these effects developing into established beliefs and to enable people to develop effective means of becoming re-established in the workplace.

For insurers, these critical factors represent a need for development in two particular areas:

l We need to continue to develop our capability within medical services and rehabilitation services to be able to intervene earlier in the course of any disability. This means increasing our ability to have an integrated approach and to be able to engage with employers as well as individuals.

l We need to continue to develop the disciplined thinking required to assess fairly those claims from people which are entirely based on subjective factors. For example, identifying the importance of understanding how psychological factors impact upon the recovery rate of a variety of physical disabilities or illnesses.

Dr Peter Dewis is chief medical officer at UnumProvident