Managed Care - July 2008 - (Page 36) higher premiums for people with positive genetic test results, they may be encouraged to charge other people with only weak indications of a future health problems more for their policies, notes Russell Korobkin, a professor of law at the University of California – Los Angeles and the author of “Stem Cell Century: Law and Policy for a Breakthrough Technology, in a recent article. And that would upset the whole notion of fair rules applied equally to all consumers. “The only way to solve the problem is to extend policyholders. Each pair included one applicant who had tested positive for an increased risk of a future health condition. Out of the 92 coverage decisions, seven included denials, policy limitations, or surcharge premiums to account for the risk. Every insurance company has its own philosophy to guide underwriters’ decisions, notes Wildsmith, and any “industry standard” for coverage decisions would probably spur antitrust concerns. So it’s not unexpected to see insurers coming up with differ- Several insurers said they would use a doctor’s consideration of surgery to prevent the risk of cancer as grounds for denying coverage or for adding a rider excluding coverage of the surgery. federal law to ban what is known as medical underwriting — basing coverage and pricing decisions on any indicators of health status — and instead require what is called community rating of all people within the same age category,” he writes. “Exceptions should be permitted to allow insurers to surcharge customers who engage in risky activities within their individual control, such as smoking.” As the science of genetics advances, calls for those kinds of reforms are likely to increase. “Dr. Collins has testified that all of us are likely walking around with dozens of genetic mutations that will someday be understood, and we’ll be able to predict what health conditions we’ll have,” says Pollitz. “Much of life’s uncertainty about health will become much more known to us, and since insurance is all about protecting people from the unknown, that will be a profound change.” So profound, she adds, that it could ultimately make the insurance industry obsolete. That’s a message that can hit hard in the underwriting community. Pollitz briefed some underwriters on the future impact of genetics and, she says, they left shaking their heads. One asked: “Who will we sell to?” Pollitz gave that briefing after she and some other researchers delved into the way that underwriters used genetic data before the law was passed. In a study published last fall, the group presented experienced medical underwriters from 23 insurance companies with a set of four pairs of prospective ent decisions when presented with the same information. The genetic tests that the underwriters looked at for the study wouldn’t be available to them now because of GINA, but the experts were stumped on one question concerning where the law draws a line between genetic data and a person’s medical history: In the study, several insurers said they would use a doctor’s consideration of surgery to prevent the risk of cancer as fair grounds for either denying coverage or adding a rider excluding coverage for the preventive surgery as a way to avoid adverse selection by an unhealthy group of people. And they saw no problem with the 43 state laws that already outlined various rules preventing genetic discrimination. “My understanding is you will still be able to look at medical records but can’t use information obtained as a result of a genetic test,” says Wildsmith. The risk can’t be factored in, but he added that he didn’t know whether physicians’ treatment decisions made as a result of the data could be considered. Wildsmith, though, says that all that should be hammered out soon. “I’m not an attorney,” he says. “Every insurance company has a compliance department. I suspect that lawyers are busy reviewing how to change policies and procedures on compliance.” And you can bet that any gray areas will be dealt with quickly. MC 36 MANAGED CARE / JULY 2008
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