It may become even more challenging to underwrite applicants with Multiple Sclerosis (MS), and that is positive news for patients. Medical advances are outpacing mortality data so swiftly that, within the decade, it could be possible for the majority of applicants to be prescribed medications for which there are currently no long-term experience studies.
Despite decades of research, the exact causes of MS are still hotly debated, and so are the implications for insurers. MS has no ‘normal course’ of progression and no cure, so it is a difficult impairment to underwrite and price. The immune system attacks the central nervous system, stripping the protective coating, or myelin, surrounding the nerves. As suddenly and unexpectedly as this “flare up” occurs, the clinical symptoms often recede; these periods of relapse-remission can vary markedly in length and severity.
Existing treatments may slow disease progression and symptoms, which are numerous but often include pain and immobility. An array of new medications and imaging modalities promise to further improve the mortality picture. Though limited, MS studies with the longest lens reveal improving mortality for patients. How can insurers navigate this ever-changing landscape? Here are a few considerations:
- Consider space and time. Accurate MS diagnosis has proven to be one of the more challenging elements of the disorder. Physicians generally rely on the McDonald Criteria, which combine the numbers of clinical episodes (MS attacks) and radiographic lesions. Physicians must ask whether the patient presents with symptoms in different parts of the body, such as vision loss and foot-numbness, or symptoms over varying periods of time. This clinical diagnosis can be coupled with the use of radiography to identify lesions in two separate areas of the brain, or note that lesions are changing over time. Without this “dissemination” in space and time, the patient may not have the disease; anyone suffering a single attack is said to have Clinically Isolated Syndrome (CIS).
- Accurately classify risk. Physicians and insurers depend on the Kurtzke Expanded Disability Scale to categorize the severity of a diagnosis by examining eight physical systems commonly affected: cerebellar, brainstem, sensory, bowel and bladder, vision, mental function, pyramidal (strength), and other neurological deficits. The resulting score, which also incorporates functional assessments, is designed to evaluate disability, but is limited in predicting mortality. Among other issues, the score weighs each system equally which is sometimes inaccurate. For example it is generally agreed that there is excess mortality risk in the presence of cognitive impairment.
- Keep current with evolving criteria. Significant 2005 and 2010 revisions have generally relaxed diagnostic criteria for MS, with major implications for insurers. Under the new criteria, physicians are detecting the disease earlier; a diagnosis can now be reached with a single radiological scan. Critical illness and disability definitions must be updated accordingly. At the same time, actuaries must now account for diagnoses at earlier ages and with milder clinical severities. Medical underwriting departments, in turn, must account for a potential lead time bias in evaluating MS research; treatments that appear to be lengthening survival may in fact just reflect earlier diagnosis.
- Recognize that medicine is advancing faster than mortality studies. Available mortality studies can be misleading; most are based on an older cohort and do not reflect newer medications and imaging technologies.
- Emerging imaging tools may enhance the speed and accuracy of MS diagnosis and could ultimately enable more tailored treatments.
- New oral therapies represent the culmination of several decades of research and were spurred in large part by patient dissatisfaction with the side effects of earlier drugs. These new drugs are transforming treatment for MS, although the mechanisms by which they control disease progression are still poorly understood.
By staying current with recent changes in definitions, medications and diagnostic tools, underwriters can better assess applicants during this time of technical and medical discovery.
After all, as the great physician William Osler once wrote, “Medicine is the science of uncertainty and an art of probability.” The same could be said of insurance.
