ENABLINGa holistic view of health

IntroductionIn a previous publication (Evolving, November 2005) we told you about changes in the way that we were proposing to organise our claims teams to reflect the knowledge we have gained at UnumProvident about the complex interaction between ill health and behaviour. This knowledge comes from our day-to-day observations of claims and also through the academic research that is being pursued by the UnumProvident Centre for Psychosocial and Disability Research and others. We believe that the biopsychosocial model of disability provides a complete view of illness, sickness and disease by putting ill health in a context which is both personal to the sufferer and takes into account the social environment he or she is in when illness strikes; in wider society as well as at home and at work.

We have now implemented the changes to our Claims Department so that we have Claims Teams that support specific brokers and their customers, which is reaping benefits in all sorts of ways for us and our clients. Not least of these is the fact that Claims Management Specialists and clients are getting to know each other better. We are definitely finding that this is leading to improved communication and enhancing our understanding of individual client needs.

Things have not stood still since then and we have made further changes to the way we work, notably in the area of medical underwriting. Our Chief Medical Underwriter, Andrew Potterton writes:

“We have changed our approach to the risk assessment of the lives we insure, whether through their employers’ schemes or our retail products. In a market leading move, we no longer obtain medical evidence simply in response to the amount of income protection benefit we are being asked to cover. Instead, our philosophy is only to call for evidence where the application disclosure demands it. It is therefore now possible to get the very high amounts of income protection cover we are able to provide on the basis of an application form alone.

Not only should we see improved completion rates as fewer applications fall by the wayside due to outstanding evidence, we also anticipate considerable improvements to the customer experience. Our innovative approach is expected to radically reduce the time it takes to get cover in place as we are now able in far more cases than before to make final underwriting decisions within days of application receipt.”

What does the Biopsychosocial Model mean for Disability Assessment?

The biopsychosocial model of disability provides a complete view of illness, sickness and disease.

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A holistic view of healthIt is important to understand why we believe the biopsychosocial model of disability is so important. In Evolving we described the model and contrasted it with the older medical model, which provides a very incomplete view of what lies behind sickness and incapacity.

It is a known paradox that with all the medical advances of the second half of the 20th century there has been a huge increase in people who are considered to be too incapacitated for work. This rise in incapacity took place from the 1980’s onwards and is seen in all developed countries. Figure 1 clearly shows this trend in the UK. It has to be remembered that this rise in incapacity did not take place as a result of any epidemic of disease or illness and therefore cannot be easily explained in medical terms.

Figure 1: Total Incapacity Benefit recipients by selected year 1981 - 20031

We know that most people who visit their doctors do not have conventional explanations for most of their symptoms and a seminal study of patients attending their Family Practitioners in the USA in the 1980’s clearly demonstrates this (figure 2).

Figure 2: Three year incidence of symptoms in general practice - Total and with identifiable organic cause2

In this study, even with apparently obvious physical symptoms such as dyspnoea (shortness of breath) and oedema (swelling due to fluid retention), no organic cause was found in most cases. It has been said that doctors spend most of their time at medical school learning about the 20% of people with physical problems and most of their time in practice treating the other 80% they were never taught about!

What impact does this have on income protection claims? Firstly, there has been no significant change in the proportion of insured lives who claim over the last ten years, in spite of better medical treatment for all sorts of illnesses and diseases. However, we are seeing a much greater proportion of claimants with mental illness as the stated reason for incapacity. This is demonstrated in figures 3 and 4.

Figures 3 & 4: Causes of Incapacity (%)

This is not easy to explain in medical terms, but if we think about perceptions of health and the way that many people now view the world of work in the light of publicity about work stress, it is easy to see how people may be more willing to come forward with a psychological explanation for their illness than before.

Thou

sand

s

Years0

500

1000

1500

2000

2500

1981

/82

1986

/87

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

0

20

40

60

80

100

Che

st P

ain

Fati

gue

Diz

zine

ss

TotalOrganic cause

Hea

dac

he

Oed

ema

Bac

k p

ain

Dys

pno

ea

Inso

mni

a

1. Source: ONS

2. Source: Kroenke & Mangelsdorff 1989

Key

• Mental/psychological

• Cardio-vasc/circulatory

• Nervous system

• Musculoskeletal

• Arthritic

• Respiratory/throat

• Cancer (tumour)

• Gastro/intestine/digestive

• Endocrine/metabolic

• Visual/auditory

• Injuries

• Aids/HIV

• Chronic fatigue (ME)

• Ill defined/miscellaneous

2004

19951995 2006

15.51 28.67

15.99 9.12

5.33 5.19

15.35 12.41

9.86 6.74

2.78 1.98

10.58 14.10

2.23 3.14

2.23 2.57

2.07 1.14

7.16 7.14

0.32 0.00

2.55 2.64

8.04 5.15

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The BPS model attempts to take a holistic view of incapacity and disability. There is more to disability and incapacity than just illness or a disease. In fact we know that with back pain, for example, factors such as job dissatisfaction and beliefs about causation of pain are more important predictors of long-term absence than what exactly is wrong with the back.

The model attempts to take these and other factors into account when predicting incapacity and devising treatments or rehabilitation programmes. We know that a belief that work has caused a back problem makes a return to work much less likely for a sufferer. Where does that belief come from? In some cases, an injudicious remark from a doctor may be the trigger. In other cases, it may be that beliefs have been acquired throughout life, either through observation of others’ behaviour or through the way our parents have treated us when we are ill. The social context can be important – if one is in a job such as nursing, where it is commonly held that work is a major cause of back pain, it is easy to see how an acute bad back may be seen as a catastrophe.

Think about heart disease. One person may suffer an attack of angina and be advised by his doctor that he is at risk of heart attack if he does too much and that he should avoid exertion at all costs. It is easy to see how that could lead to a cycle of physical deconditioning and a downward spiral into serious ill health. Imagine the converse: the doctor advises that angina attacks are due to the heart’s requirement for blood temporarily exceeding the supply as a result of exercise. He or she then goes on to say that the best way of helping this is not to avoid exertion but to gradually increase one’s fitness. In this way alternative routes of circulation may open up, and the heart will become more conditioned to greater demands. It is easy to guess who will be the most incapacitated, and also which person will die sooner. Imagine the added effects of family advice and also personal experience or knowledge of other angina sufferers on the behaviour and health of the individual.

The biopsychosocial model seeks to remind us of all the factors which come into play. Think about going to work every day for a boss who constantly belittles you or where you have no interest in your work or relationships with your colleagues. Think about what would happen if you developed a bad pain in your neck that made it difficult for you to get to work. It is easy to see how one or two days off could stretch into several, and then how, when you do go back with your neck still sore, you wonder why you did. Staying off sick can seem a sensible option. Unfortunately when you eventually go to your doctor, he is very busy and advises you to stay off until you have seen a physiotherapist. The appointment takes a few weeks to come through and you have been doing nothing to get your neck better. Fear avoidance leads you to restrict your movements and you develop protective muscle spasm. The NHS physiotherapist has no interest or time to deal with your fears and worries and does little to encourage activity. Is it any wonder that events conspire to lead to quite severe incapacity?

Such incapacity can be absolutely genuine, but at the same time completely dysfunctional and harmful. When illness behaviour of this sort becomes established it can be very resistant to conventional treatment. A belief that pain is harmful and indicates more damage, and an expectation that others are responsible for curing you are two more pieces of what is now starting to look like a very complicated jigsaw.

What is the Biopsychosocial (BPS) Model?

The BPS model attempts to take a holistic view of incapacity and disability.

There is more to disability and incapacity than just illness or a disease.

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Illness and DiseaseMany people confuse illness with disease, when in fact they are distinct, although related phenomena.

What is a disease?

A disease is a pathological process in the body which can be detected or measured. Type 1 Diabetes Mellitus is a disease. The body produces insufficient insulin to enable its cells to absorb sugar and metabolise it. The sugar circulates uselessly in the blood and leaks though the kidneys into the urine. This leads to the kidneys letting more water leave the blood as well. Because the cells are unable to utilise glucose, they start to burn fat instead - this leads to metabolic acidosis because of the chemical reactions involved. If left untreated the diabetic person loses weight because they have to burn fat, becomes dehydrated because they lose so much water through the kidneys and eventually death will occur. Insulin can and does prevent all this. A person with well-treated diabetes still has the disease but may not be ill at all.

What is an illness?

An illness is the experience of ill health or disease. The diabetic who has not yet been diagnosed will experience fatigue, thirst, frequency of passing urine, and weight loss. Often they will wait a long time before going to the doctor and may not interpret their problems as illness until they are very severe.

By definition, some illnesses occur in the absence of disease. Irritable Bowel Syndrome is one such illness. Affected people may suffer from constipation, diarrhoea and abdominal pains. If on investigation a problem such as an infection or inflammation is found as the cause then the diagnosis becomes that underlying cause.

This all sounds complicated, but it is crucial to understanding what happens in illness. Think about a crowd of people going on a roller coaster. Many will enjoy it, and some may want a second ride. Others will not be so sure and one or two may find the experience totally traumatic. How can this be? They have all been through exactly the same experience. In a physical sense they have all been through the same thing, but subjectively no individual’s experience will be completely the same as any others. What determines that subjective experience? It is hard to say, but previous life experience will be important. Have they had a bad experience on a similar ride? Did people in the queue for the ride ‘wind up’ their negative expectations? Were they brought up by overprotective parents and developed negative and fearful expectations of life? The fact is that no one thing will be to blame and what leads to people reacting and behaving in a certain way is complex and not easy to predict.

It is just the same with ill health.

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What does this mean for UnumProvident’s customers?This does not mean that every illness is in the mind. Nor does it mean that people who choose not to work because of ‘imagined’ problems should not have their eligibility for benefit assessed. However, it still means that we should have expectations for behaviour and capacity in illnesses.

When assessing claims we look for the “three C’s” – credibility, consistency and consensus. We also have reasonable medical expectations based on diagnosis. The diagnosis is important, because it assists us in deciding expectations. We look for some form of reasonable relationship between the illness and the claimed incapacity - in other words credibility. We look for reasonable consistency between reports from doctors and what the claimant tells us, and whether the activities performed in his or her daily life are actually consistent with an ability to perform the insured occupation. Finally, we look for agreement between the various opinions that we seek whether from treating or independent doctors – consensus.

Once the diagnosis has been established and expectations set, it is easy to see how the management and assessment of claims is actually very similar, whatever the initial cause of the incapacity. We need to understand those cases where there are positive restrictions (things people should not do) and where we may expect limitations (things people cannot do or find difficult to do). Managing such cases onward is then largely independent of diagnosis.

Finally, we need to be aware of co-morbidity (the presence of two diagnoses – typically the primary physical problem and a secondary psychiatric one).

ClaimsOur new team structure is no longer based around different impairments, but is now client-centred. This means that we have expertise in all claims spread throughout our two offices and the various teams. Nurses are still positioned within the teams and we still have our two doctors. This means that we can set reasonable expectations in the light of the medical information and also still have access to expert interpretation of medical reports. In particular, it means that we have psychiatric expertise much more readily available to all Claims Management Specialists (CMS’s). This enables us to identify much more readily those cases where depression or other psychiatric illness lie behind or complicate the medical presentation of incapacity.

An added advantage is that as CMS’s get to know their customers they are becoming much more aware of potential work issues behind claims, and also what steps our customers may be able to take in assisting a return to work. We are already seeing that as relationships develop between CMS’s, intermediaries and customers they are each gaining a greater understanding of each others’ positions, problems and capabilities. This is leading to much improved customer service and satisfaction. The fact that Rehabilitation Services are already aligned with brokers and clients has also led to streamlining and better working together.

What keeps people off sick often has little or no relation

to what they went off with in the first place.

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Medical UnderwritingOne of the benefits of our new income protection underwriting philosophy is the reduction in the amount of medical evidence we require. In most cases, we have found the evidence adds little to our knowledge of the risk. It is far more useful to gather the information we need from the life to be insured who is, after all, most knowledgeable about those biopsychosocial risk factors that interest us.

The application form inevitably runs to more pages than you have been used to and its style is also different, as it contains a series of behaviour-based questions that give us a picture of the applicant’s attitude and approach to health. The application form aims to promote a sensible conversation with the applicant and to encourage full and frank disclosure, with the important benefit of reducing the potential for non-disclosure.

Application questions are designed to be answered to the best of the applicant’s knowledge, and we do not expect facts to have to be checked with employers, doctors or family members. Rather than insisting on the specific date of an event, for example, we ask only for the month or, if further back in a person’s history, only for the year.

We believe our move away from diagnosis-based underwriting to a decision-making process linked far more closely to applicant behaviour and attitude is a significant first step towards being able to predict the resilience of our insured population. We do not expect our overall standard: adverse risks ratio to change and we see no reason why we should not continue to accept around 75% of applications on standard terms.

An applicant’s work absence record and GP consultation pattern, when added to a history of medically unexplained symptoms, may well steer the underwriter towards an adverse terms decision, whereas medical conditions previously considered to carry extra or even uninsurable risks, may well fall into an improved risk category.

Two examples of this:

We insure applicants with paraplegia at standard rates if the condition is due to injury, it does not affect occupational performance and there is full psychological adjustment to it.

We also have affordable rates for applicants with diabetes who understand their condition, comply with their treatment and advice and, importantly, have an optimistic outlook.

In fact, we are currently exploring other opportunities to open up the valuable benefits our cover provides to more and more people. We would very much like one day soon to accept the risk of further incapacitating heart attack in applicants who can demonstrate a positive response to their first mild one, in terms of compliance, adjustment, optimism and return to work in an appropriate timescale.

There is also a significant beneficial impact for our Group Life customers in all of this. Picking up on the point about the value of medical reports in understanding risk, we have decided to no longer obtain GP reports simply in response to the amount of death benefit we are being asked to cover. Instead, as with income protection, we shall only call for a report where the application disclosure demands it. Added to this, we have substantially increased the levels of cover at which we require a member to attend for medical examination, HIV test, blood profile (cholesterol, kidney and liver function and other tests) and exercise electrocardiography.

We have every confidence our new underwriting approach and the application form that goes hand in hand with it enhances our ability to predict the risk of incapacity without diminishing our life underwriting capability. We have been mindful of our customers (adviser, policyholder, employer and member) throughout and we are very grateful to the many Independent Financial Advisers who have helped us to ensure this initiative also has clear advantage for our customers.

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Rehabilitation ServicesDoes this mean any changes for Vocational Rehabilitation? Our model of Vocational Rehabilitation was one of the first areas where we implemented a biopsychosocial approach to illness. Our model addresses barriers to return to work, whether physical or psychological, and looks to facilitate removing or minimising them. In some cases there is a fear that work will cause damage or harm. In others there may be actual physical difficulties caused by the nature of the health problem coupled with the type of work involved. Of course, such problems will coexist to a greater or lesser extent in the majority of people who have been away from work for a while.

In some cases, working with the employer to address fears and worries expressed by the claimant is all that is required. In others, overcoming physical barriers by either making adjustments to the place of work, work hours or equipment used is necessary. Obviously, a combination of both approaches will most often be the most valuable.

The biopsychosocial model tells us that what keeps people off sick often has little or no relation to what they went off with in the first place. Early intervention can prevent harmful ideas or beliefs becoming embedded and we like to encourage engagement at the earliest practicable or reasonable opportunity. Simple interventions are often the most effective in achieving return to work or preventing prolonged absence. It is for this reason that we at UnumProvident direct our energies at providing an enabling model of absence management and have invested so much in Vocational Rehabilitation as opposed to other more traditional areas of Occupational Medicine.

ConclusionAt UnumProvident we believe that the only way to ensure that our claimants and customers receive the help that they really need is by understanding as fully as possible what lies behind illness and incapacity. Just understanding is not enough, we have to ensure that this understanding is correctly applied to ensure that we all reap the benefit.

Long term incapacity is not just a problem for the individual who is sick, but represents a problem for the employer who has to go to the expense of making alternative arrangements or even replacing individuals who will never return to work. Such situations are avoidable and preventable.

Our Customer Care claims philosophy is:

We will provide the highest quality disability risk management service to our customers by:

• Paying the right benefit to the right people

• Helping people back to work

We believe that we are making very positive moves to make that philosophy even more relevant, by ensuring that we learn from experience and by fully embedding the lessons that we learn from our academic colleagues at the UnumProvident Centre for Psychosocial and Disability Research.

Michael O’Donnell, Chief Medical Officer, UnumProvident

We direct our energies at providing an enabling

model of absence management.

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About UnumProvidentUnumProvident is the UK’s leading provider of group income protection insurance, with over 35 years of experience. Our critical illness and life insurance products enable our customers to purchase complementary protection solutions that together make a comprehensive protection package.

Our income protection customers benefit from our expertise in the specialist areas of disability, rehabilitation and return-to-work. We enable individuals to protect their incomes, ensuring their financial security if they are unable to work because of illness or injury. For employers, we safeguard one of their most valuable resources by helping employees return to work following long-term absence.

At the end of 2005, UnumProvident protected over 2.3 million lives through almost 20,700 schemes. During 2005 we paid total benefit claims of £291 million – of which more than £185 million related to income protection claims.

Our US parent company, UnumProvident Corporation, traces its history back to 1848 and is today the market leader of group and individual income protection insurance in the United States. Premium income for UnumProvident Corporation and its subsidiaries exceeded $7.8 billion in the year ended 31 December 2005. Total assets were $51.9 billion at 31 December 2005.

For more information visit www.unumprovident.co.uk

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Unum Limited, trading as UnumProvident, is authorised and regulated by the Financial Services Authority. Registered in England 983768. Registered office: Milton Court, Dorking, Surrey RH4 3LZ. Tel: 01306 887766 Fax: 01306 881394 Textphone: 01306 887784

We monitor telephone conversations and e-mail communications from time to time for the purposes of training and in the interests of continually improving the quality of service we provide.

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www.unumprovident.co.uk

UP1268 09/2006