DISEASE TRENDS Challenges and Opportunities · DISEASE TRENDS Challenges and Opportunities ......
Transcript of DISEASE TRENDS Challenges and Opportunities · DISEASE TRENDS Challenges and Opportunities ......
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Southeastern Actuaries Conference
Mark Skillan, M.D.
June 20, 2014
DISEASE TRENDSChallenges and Opportunities
Leading Causes of Death and Disease Trends in the U.S.
Select Areas of Interest
Heart Disease
Diabetes
Cancer: Lung, Breast, Prostate, Colon, Melanoma
HIV
Added Challenges in Risk Selection
e-Cigarettes
Gender Identity
Genetic testing/rare Diseases
Agenda
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Age adjusted and crude death rates in U.S. 1960-2010
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Leading causes of death in the U.S.2010
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1. Heart Disease
6. Dementia (Alzheimer’s)
2. Malignant Neoplasm (Cancer)
7. Diabetes
3.Chronic Lower Respiratory
Disease
8. Kidney Disease
4. CerebrovascularDisease (Stroke)
9. Flu and Pneumonia
5. Accidents (poisoning, MVA,
etc.)
10.Suicide
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Leading causes (continued)
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11. Septicemia (overwhelming
infection)
12. Liver Disease/Cirrhosis
13. Hypertension 14. Parkinson’s15. Other
Pneumonia’s
Life expectancy 78.7 years, continuing upward trend Age-adjusted death rate declined to a record low Homicide dropped from top 15 – first time since 1965 Lower death rates for ASCVD, cancer, lower respiratory disease, stroke, flu, pneumonia and septicemia
Highlights
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Death rates by age and gender 1955-2010
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Age Adjusted death Rates for Selected Leading Causes of Death 1958-2010
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Heart disease
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Heart disease
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Leading cause of death for both men (>50%) and women
600,000 deaths per year (385,000 from CHD)
Incidence Trend Increasing with aging population and prevalence of overweight/diabetes
Mortality Trend Steady decline in age-adjusted death rate since 1980* Decreased 2% for 2010
* except for small increase in 1993
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Heart disease – trends and implications
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Mortality improvements related to risk factor modification ….and better care
High blood pressure – improved Lipids – definitely improved Smoking cessation – improved Diabetes – improved in some groups Overweight/obesity – not so much Physical inactivity – improved in some groups Excessive alcohol – awareness improved
Improved meds – cardiac, BP, lipids
Improved care – diagnostics, PTCA, ICU/CCU, cardiac rehab, etc.
Trend likely to continue though impact of overweight/obesity may offset gains… © 2014 Munich American Reassurance Company. All rights reserved.
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Diabetes
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Diabetes – 7th leading cause of death – likely an underrepresentation
Estimated risk of death is about twice that of people of same age without diabetes
Associated complications: Heart disease 2-4x risk Stroke 2-4x risk Hypertension – present in 67% of adults with DM Vision impairment/loss, a leading cause of acquired blindness Kidney disease – cause in 44% of new cases of renal failure Nervous system disease – leading cause of sensory, digestive issues, ED, CTS Limb loss – 60% of non-traumatic lower limb amputations are DM related
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Diagnosed diabetes, U.S. 1958-2010
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Obesity and diabetes U.S. adults 1994-2010
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Diabetes by age
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Age ≥ 20 years 25.6 million - 11.3% of all people in this age group
Group Number or percentage who have diabetes
Age ≥ 65 years 10.9 million - 26.9% of all people in this age group Men 13.0 million - 11.8% of all men aged 20 years or olderWomen 12.6 million - 10.8% of all women aged 20 years or olderNon-Hispanic whites 15.7 million - 10.2% of all non-Hispanic whites aged 20 years or olderNon-Hispanic blacks 4.9 million - 18.7% of all non-Hispanic blacks aged 20 years or older
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Age group and diabetes
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Newly diagnosed diabetes, adults2010
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Trends and implications - Diabetes
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No change: 36.6% in 1994
36.1% in 2010
Worse: 40.2% in 1995
58.4% in 2009
Worse : 69.7% overweight in 1994
84.7% in 2010
Some improvement of Hemoglobin a-1-c levels:- some increase in best controlled
- some decrease in poorly controlled
Minimal change in BP control
Minimal: 21.7% smoked in 1994
19.9% in 2010
Increased: 46.2% in 1995
57.1% in 2009
Glucose Control1988-2006
Prevalence High Blood Pressure 1995-2009
Blood Pressure Control1998-2006
Smoking Cessation1994-2010
Weight Control1994-2010
High Cholesterol1995-2009
Physical Inactivity1994-2010
Progress in modifying risks for DM complications
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Diabetes trends and implications continued
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35% of persons in the U.S. over age 20 have
pre-diabetes
50% of persons in the U.S. over age 65 have
pre-diabetes
Outlook appears unfavorable given the high prevalence of overweight and obesity as well as limited progress on controlling factors which lead to complications
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Breast Cancer
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Most common cancer in women 207,000 women, 2000 men in 2010 Second most common cause of cancer death in women (first among Hispanic)
Incidence trends, 2001-2010 – remained level
Mortality trends, 2001-2010 – decreased 1.5-2.0% per year
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Earlier diagnosis Better treatment
Risk of breast cancer increases with age
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Traditional Approach to Underwriting Cancer:T2 N1mi M0, G2, ER Negative Breast Cancer, Ages 50 - 69
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Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4
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0.5
0.6
0.7
0.8
0.9
1
1.1
0 2 4 6 8 10 12 14 16
% S
urvi
val
Year
“Postpone” = cut off steep part of mortality curve
O
E
T2 N1mi M0, G2, ER NegativeAges 50 - 69
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0
10
20
30
40
50
60
70
80
0 2 4 6 8 10 12 14 16
ED / K
Year
Year Total ED / K Remaining
5 159
6 116
7 61
8 23
+ 100 (Table 4)
Year Flat ExtraED/K
Remaining5 30 / m x 5 Y 1596 25 / M x 4 Y 1167 20 / M x 3 Y 618 12 / M x 2 Y 23© 2014 Munich American Reassurance Company. All rights reserved.
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Screening mammography has resulted in twice as many early stage breast cancers being detected yearly
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Figure 1. A
Women > 40 years of age
Bleyer A and Welch HG, NEJM 2013;367(21):1998 – 2005.
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Early Stage (T1, T2) Breast CancerDistribution by Stage and Age
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0
10000
20000
30000
40000
50000
60000
T1a T1b T1c T2
70 - 79
50 - 69
30 - 49
Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4
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Early Breast Cancer: T1c N0 M0, Grades 1 and 2,Ages 50 - 69
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Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4
Survival curve is convex and similar to expected mortality
Earlier Dx
Improved Rx
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Long-term adverse effects from therapy for early stage breast cancer result in ongoing increased mortality risk
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Radiation Increase incidence of coronary artery disease Myocardial damage from radiation
Chemotherapy
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Increased incidence of hematologic malignancies Cardiomyopathy
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Early Stage (T1 T2 N0 M0) Breast Cancer
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Survival curves are convex
Little advantage to postpone period
Debits better reflect the risk vs. temporary flat extra rating format
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Menopause and Age alter mortality risk in early stage breast cancer
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Menopause and age have measurable influences on mortality with breast cancer
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T N M Stage Grade Mortality Ratio
Below 50 Years
50 – 69 Years
70 Years & Above
T1a, T1b N0 M0 1 & 2 143 96 94
3 209 105 94
T1c N0 M0 1 & 2 214 115 104
3 299 125 111Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4
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And above age 70…
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Early Stage breast cancer (T1 size) effectively treated with lumpectomy and tamoxifen
More sensitive to effects of hormonal Rx in later years –especially beyond 75 years
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Women 70 Years or Older, T1 N0 M0, ER + Breast Cancer and Clinically Negative Axilla – No Increased Mortality
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No survival benefit by adding RT to tamoxifen
Mortality Ratio = 97%
Only 1.5% later develop + axillary lymph nodes
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Hughes KS, J Clin Oncol 2013;31:2382 – 2387.
T1C LN Status Undefined, Grade Undefined, M0Ages 70 and above
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20.00%
40.00%
60.00%
80.00%
100.00%
0 5 10 15 20
Observed
Expected
Mortality Ratio = 104 % Minimal excess late mortality for T1C breast cancer without consideration of axillary lymph node status in ages 70 & above
0
0.005
0.01
0.015
0 2 4 6 8 10 12 14 16
Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4© 2014 Munich American Reassurance Company. All rights reserved.
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Early Stage Breast Cancer: T1 and T2 Disease, Negative Lymph Nodes, No Metastatic Disease
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Debits better reflect risk than temporary flat extra’s
After year 1, additional PP period not warranted
Persistent increased mortality of minimal degree
Adequately treated with lumpectomy & tamoxifen
Surgical lymph node evaluation not required
Post-menopausal mortality significantly better
Convex Survival Curves Age Banding & The Menopause Ages 70 & Above with Clinically Negative Axilla
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Trends and implications – Breast Cancer
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With aging population and better screening, incidence likely to riseOutlook for early stage breast cancer has improved
Improved understanding of the most common breast cancer risks encountered:
More limited PP period translates to earlier offers Small rating, no temporary extra premium charge Bottom line: More and more favorable offers than in past
For applicants with early stage breast cancer within 5 years of therapy
For the balance of the policy, more accurate pricing of the risk
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Extra mortality for those entering insured pool after traditional PP period was often not previously covered
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Lung Cancer
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More Americans die from lung cancer than any other cancer Diagnosed: 201,000 – M:F 107,000: 94,000 (2010) Deaths: 158,000 – M:F 88,000: 71,000 (2010)
Incidence trends 2001-2010
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Decreased 2.3 – 2.7% per year in men Decreased 0.6 – 0.7% per year in women, stayed level in black women
Mortality trends 2001-2010 Decreased 2.5 – 3.3% in men, biggest improvement among black men Decreased 0.9 – 1.0% in women
Trends and implications – Lung Cancer
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Decrease incidence and mortality in men reflects smoking reduction over past 20-30 years in men
Lack of improvement in women likely reflects both later adoption and discontinuance of smoking among women
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Screening remains problematic and controversial – CXR, CT, etc
Therapies except for the earliest found lesions and one subgroup (NSCLC) remains less than optimal
Key to future remains risk factor reduction
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Colorectal Cancer
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Third most common cancer in men and women Diagnosed: 132,000 – M:F 68,000: 64,000 (2010) Deaths: 52,000
Incidence trends 2001-2010 Decreased 2.0 – 4.0% per year in men Decreased 2.0 – 3.3% per year in women
Mortality trends 2001-2010 Decreased by 1.4 – 3.0% per year in men Decreased by 2.0 – 3.3% among women
Second leading cause of cancer death in cancers which affect both men and women
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Trends and implications: Colorectal Cancer
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Education, screening and surveillance has had a favorable impact More earlier stage lesions at diagnosis Able to offer on best cases and do so earlier
Incidence increases with age thus incidence likely to increase Treatment for later stage disease remains sub-optimal Current ratings for these may be underpriced in the market
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Prostate Cancer
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Most common cancer among men in U.S. Lifetime risk >16%
Second leading cause of cancer death in men
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Diagnosed: 196,000 in 2010 Deaths: 29,000
Incidence trends 2001-2010 Decreased by 2.6 – 4.0% per year
Mortality trends Decreased by 3.0 – 3.8% per year (3.8% in black men!)
Trends and implications – Prostate Cancer
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PSA and DRE screening has resulted in earlier detection More earlier stage lesions
Key risk indicators
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Age at diagnosis - <55, 55-60, 60-69, 70-74, 75+ Stage of disease – local (T2 or less) or extra-capsular (T3 and above) Tumor grade – Gleason score (2-10)
Post-treatment PSA level
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Trends and implications – Prostate Cancer(continued)
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With latest SEER data, improved ability to quantify risk Earlier offers for better/best risks Better offers for many than before, especially at >60, >70
Second leading cause of cancer death in men
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Controversy over screening/over-treatment may lower detection of early tumors More men may elect “watchful waiting” Focus on ED risk may likewise affect number of younger men opting for radiation rather
than surgery with less certain outlook for cure in some cases
Skin Cancer - Melanoma
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Skin cancer is the commonest form of cancer in the U.S.Most are basal cell or squamous cell cancers with minimal mortality impact
Melanoma is potentially a bad actor Diagnosed melanomas: 61,000 M:F 35,200:25,800 in 2010 Deaths: 9,200 M:F 6,000:3,200
Incidence
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Increased by 1.6% per year in white men, remained level in others Increased by 1.6% per year in white women, remained level in others
Mortality Increased by 1.0% per year in white men, remained level in others
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Trends and implications: Melanoma
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Education and screening has had an impact but this is likely being offset by Growth of aging population More outdoor activities Increasing residency in warmer climates Inadequate adherence to SPF protection measures
There is more data on mortality risk based on microscopic findings (stage, grade) atdiagnosis and other prognostic indicators
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Improved offers for earlier stages with good prognosis markers Later stages remain problematic Newer therapies show promise
HIV Disease
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Mortality trend for AIDS (Stage 3 HIV disease)
HIV infection incidence trend Remains level – 50,000 new infections per year M:F 39,000:11,000 Most new infections ages 20-50 Highest risk groups unchanged
A leading cause of death ages 15-64 1.2 million AIDS cases to date, cumulative deaths 636,000 Declining – 15,000 deaths in 2010
Prevalence of HIV infection in U.S.: 1,100,000 (180,000 or 16% unaware)
Recent advances in therapy (ART) appears to have changed the course for HIV disease
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Natural history of untreated HIV infection
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Trends and implications: HIV Disease
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Remarkable progress has been made in therapies since 1995 The latest drug combo’s appear to be effective over the long term (so far) with much more limited side effects than their predecessors There are reliable prognostic markers (CD4 count, HIV viral load, etc) Insurance (including whole life) is being offered in some other countries Just another chronic disease? Challenges include
niche market the newer drug regimens are relatively novel (?2006) even if HIV is successfully suppressed, there appears to be some increased risk for non-HIV related death (CAD, etc), i.e., premature aging
A vaccine to prevent HIV infection seems a long way off. PreP for those at risk is here but not a panaceaA long-acting pre-exposure prophylactic medication may be available near term
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HIV (+) Death Rate After ART Initiation
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Is HIV An Insurable Risk for Life Insurance?
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e-Cigarettes: ToB or not ToB
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Cigs Appeal
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e-Cigarette components
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The Market – projected to be $6B by 2016
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e-Cigarette Challenges
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Nicotine Delivery Device or Stop Smoking Aid ?
Rapidly expanding market with huge money issues: profits, taxes
No current way to distinguish cotininesource - from smoking or vaping?
Nicotine has known medical toxicities and can be very addictive
Nicotine content may be variable depending on the source
Ability to modify content with refillable canisters
Effects of long term inhalation of propellant/nicotine vapor contents unknown
Effect on future use of other nicotine products unclear
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Gender Identity
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Whose decision is it… anyway?
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Gender identity vs. chromosomal make-upWhich should prevail when applying for insurance? Activity in legislatures in 2013, more likely in 2014-15 Implications for insurers
gender specific conditions remain, e.g., prostate cancer, ovarian cancer, breast cancer supplemental hormone use side effects mental health issues may be part of the picture in some cases
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Genetic testing
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Genetic information
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Medical, legal, social debates likely to re-surfaceWho can view a person’s genetic information?What constitutes genetic information?
Insurers view genetic information as medical information
Improving genetic tests (now at the research level) will highlight the issues
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Become less costly to perform Direct to consumer testing (23 and me, etc) is far from perfect - now Genetic links to uncommon disorders are being uncovered Medical and actuarial data for uncommon disorders remains limited
Insurers will want to continue to “Do The Right Thing” but difficult challenges likely lie ahead
Thank you very much for your attention
Mark Skillan, M.D.
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