Managed Care - July 2008 - (Page 33) to cancel their policies, then only the sick or those people likely to become sick will buy insurance, possibly bringing on legislative mandates to keep the coverage pool broad enough and deep enough to keep rates down. Eventually, the insurance industry’s whole approach to health and risk could be radically altered. “Insurance today is all about covering unknown risks, and underwriting is making sure we can make a distinction between what is known and what is unknown,” says Karen Pollitz, the director of Georgetown University’s Health Policy Institute and lead author of a study on underwriting practices published late last year in the journal Inquiry. “In the future, there won’t be a distinction.” The genetics mandate? Changes in the law haven’t quieted a chorus of critics who believe that insurers are given far too much leeway in deciding which individuals are covered, what they pay, and whether specific conditions are excluded from coverage to blunt the insurer’s risk. The individual health insurance market “is still the wild, wild West for America’s health care consumers,” claims Ron Pollack, executive director and vice president of Families USA. In mid-June the organization published a 50-state survey focusing on the widespread use of practices like cherry-picking healthy members and rejecting the sick, rescinding policies at will, or refusing to pay claims based on Lacking knowledge, but making decisions aren Pollitz at the Georgetown University Health Policy Institute led a study last fall, before passage of the Genetic Information Nondiscrimination Act, that asked experienced medical underwriters for 23 insurers what they knew about the genetic tests that were on the market and how they would handle the data. To get a better idea of how insurers were handling genetic test results, the researchers concentrated on a handful of relatively well known tests, including tests for BRCA mutations, which have been linked to a significantly higher risk of breast cancer. The responses were decidedly mixed. K Level of knowledge Condition/test BRCA in cancer survivors BRCA in unaffected patients Hemochromatosis Testing for cardiovascular disease None at all 5 6 8 15 High 10 13 10 3 Some 2 1 2 2 No answer 6 3 3 3 Lifetime cancer risks associated with BRCA 1 / 2 mutations Cancer site Breast Second breast cancer (opposite breast) after an initial diagnosis Ovarian Other Risks in BRCA 1 / 2 carriers 0% to 85% (high incidence of premenopausal breast cancers) 40% to 60% 10% to 40% (higher in BRCA1) Elevated risks of cancers of the prostate Male breast, pancreatic 8% 0.5% to 1% per year after diagnosis <2% Rare, except for prostate cancer Risks in general population Source: Pollitz K, Peshkin B, Bangit E, Lucia K. Genetic discrimination in health insurance: Current legal protections and industry practices. Inquiry. 2007. 44: 350–368. JULY 2008 / MANAGED CARE 33
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