Several of the sessions at the ICLAM meeting at the end of May 2013 in Madrid dealt with predicting cardiovascular risk. The ECG, and especially the resting trace, is a pathetically weak tool alongside the heavyweight imaging techniques – but at least it’s cheap. Of modern, sophisticated tools like the stress echo, stress single-photon emission computed tomography (SPECT), stress MRI and CT coronary angiography, it is apparently the last-mentioned that is the most powerful in identifying lesions and thus predicting risk.
But we should not forget coronary calcium scoring, carotid artery 3D ultrasound scanning and 2D carotid scanning to determine intima-media thickness, as well as ankle-brachial index (the ratio of blood pressure at the lower leg compared with the arm). All are indicators of coronary and cardiovascular risk, and apparently carotid intima-media thickness is a predictor of all-cause mortality too.
These medical advances present questions and challenges for insurers, reinsurers and their underwriters:
- Will these tools remain as investigations for the unwell, or will they be used to screen the currently well in the quest for more effective disease prevention? And if the latter, who will be screened? Those displaying CV risk factors or everyone past a certain age?
- Will underwriters use the results of these tests only because they are reported on APSs? (In which case the impact on the underwriting world will be relatively slight.)
- To what extent will they be viable screening tools for life insurance purposes? (It was predicted that within five years 3D carotid ultrasound scanning will be available for 50 dollars; this was from world-renowned cardiologist Dr Valentin Fuster, so we should sit up and take notice.)
- If ordinary folk can walk into a clinic and be tested for 50 bucks, what is the potential for antiselection?
Any answers would, at this stage, be mere speculation, but these are issues to keep awareness of. Answers will be required at some stage.
However, these matters make you realize that there is, if you like, an increasing tension between modern high-tech medicine and life/disability insurance. Investigative medicine gets ever more sophisticated – but does insurance have to go there too? Inevitably it does in the case of impaired risks. But for other lives? It is interesting that while doctors and scientists are making medicine more complex to make it better, insurers are looking to make their processes simpler and cheaper, to make it easier for consumers to buy, to make insurance a more attractive, maybe less intimidating proposition. Predictive modelling and 3D imaging studies are in many ways at the opposite ends of the risk information spectrum.
How much info do insurers need to price a risk and reduce antiselection to acceptable levels (and still have an appealing, competitive product)? There is maybe a temptation among underwriters to keep on stratifying risk if the ability is there. But just because you can find out, do you always need to? After all, folks are only buying insurance (as we’ve said before).
It’s important not to lose sight of the bigger picture. But as the ICLAM sessions illustrate, the world is moving on apace, and what is sound philosophy now may not be appropriate in a few years’ time.