Implications For Insurance Research Articles

Briefly Noted

For decades, Herbert Kleber, M.D., had been one of the country's most important researchers in substance use disorder treatment. He died last month of a heart attack while on vacation in Greece with his family. He was a pioneer in addiction treatment, focusing on the need for evidence in the 1970s, when the entire field was barely taken seriously. His insistence on randomized controlled trials and placebo comparisons helped give the field credibility. He even spent two years working at the newly minted Office of National Drug Control Policy, but it wasn't a good fit for him, as he was a treatment, not a “war on drugs,” proponent. At Columbia University, he established the division on substance use disorder with addiction researcher Marian Fischman, Ph.D., his second wife, who died in 2001. When he died, Kleber was still professor of psychiatry there, and emeritus director of the division. We interviewed him many times over the years; he was always generous with his comments and analysis. He was co‐author of the seminal “Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation,” which he wrote with A. Thomas McLellan, Ph.D.; David C. Lewis, M.D.; and Charles P. O'Brien, M.D., and was published in the Oct. 4, 2000, issue of the Journal of the American Medical Association.

English

When distribution is neglected, micro insurance fails. This considered, the objective of this study was twofold – to explore the nature of micro insurance distribution channels and to understand the distribution strategy of a commercial insurance company in Swaziland. Using interviews with the senior managers of a commercial insurer and its distribution partners, this study generated in-depth qualitative data on their experience and recollections of the nature of channels and the strategy of distributing micro insurance. In this study, the commercial insurer leveraged predominantly on non-traditional channels such as churches, post offices, and cooperatives. These are characterised by access to large groups of potential clients and the trust of the community – but were initially incapacitated by a lack of technical expertise in terms of being trusted business associates and trusted advisors to micro insurance clients in Swaziland. Four inextricable components – depicting novel partnerships, ease of doing business, channel communication, and bringing micro insurance close to the people – encapsulate the distribution strategy of the commercial insurer. Among the key imperatives for cost-effective distribution of micro insurance are tailored channel development, consumer education, and segmentation of non-traditional channels to match low-income clients. Given the findings, a simple framework of micro insurance distribution and implications for research are proposed.   Key words: Micro insurance distribution, distribution strategy, service distribution. &nbsp

Disparities in health-related quality of life in women undergoing treatment for advanced ovarian cancer: the role of individual-level and contextual social determinants.

Social determinants may influence health-related quality of life (HRQOL) among women with ovarian cancer, potentially creating disparities in clinical outcomes. We investigated the relationship between HRQOL and social determinants of health, including travel distance to access cancer care and health insurance type, among women participating in a randomized trial of primary adjuvant treatment for advanced ovarian cancer. The Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaire captured HRQOL (physical well-being, functional well-being, ovarian-specific, and trial outcome index [TOI]) prior to chemotherapy (baseline), during the trial, and 84weeks after initiation of chemotherapy for women with advanced epithelial ovarian, primary peritoneal, or fallopian tube cancer. We constructed bivariate and multivariable linear mixed effects models examining the associations of social determinants of health (individual-level and contextual factors) with HRQOL scores at 84weeks, clustering participants (n = 993) within treatment centers, and Census regions and controlling for baseline HRQOL. Most individual-level (race, age, cancer stage, adverse events) and contextual (travel distance to treatment center, community socioeconomic status) factors were not statistically significantly associated with HRQOL. Compared to participants with private health insurance, other participants had lower mean HRQOL (physical well-being: public insurance, - 1.00 (standard error[SE] = 0.49) points, uninsured, - 1.93 (SE = 0.63) points; functional well-being: public, - 1.29 (SE = 0.59), uninsured, - 1.98 (SE = 0.76); ovarian cancer-specific: public, - 1.60 (SE = 0.59), uninsured, - 1.66 (SE = 0.75); TOI: public, - 3.81 (SE = 1.46), uninsured, - 5.51 (SE = 1.86); all p < .05). Private health insurance was associated with improved HRQOL at the completion of treatment for advanced stage ovarian cancer. Implications of health insurance on HRQOL should be further investigated, particularly among women with ovarian cancer who receive standard of care treatment.

How Lacrosse and Grenfell have dramatically altered the litigation and regulatory landscape

The health and safety, compliance, regulatory and insurance implications posed by cladding are immeasurable. The associated risks they present simply unquantifiable. This paper compares how the fire at Lacrosse in 2014 and Grenfell in 2017 have dramatically altered the litigation, regulatory and compliance landscape. How governments, regulators, building practitioners, legal practitioners and owners and residents of buildings fitted with ACP cladding will ultimately adapt and conform to this new and rapidly changing landscape is yet to be seen.

Misrepresented Interests: Business, Medicare, and the Making of the American Health Care State

A belief that there is a pervasive and enduring adversarial relationship between business and the welfare state is shared widely across scholarly disciplines engaged in historical and comparative analysis of social politics. According to that view, each stage in the expansion of the American welfare state was a defeat for capitalists. Detailed evidence on the politics of health care, with special focus on the passage of Medicare in 1965, casts serious doubt on this dominant view about class politics, the welfare state, and the power of business. It shows that much of the literature takes a hazardous inferential leap from national business organizations’ official positions against reform to overconfident conclusions about actual business opinions. The literature also mistakenly discounts evidence of business support for moderate reforms as strategic camouflage of actual opposition designed to head off more radical ones. Extensive evidence reveals enormous division within business rather than unity about the health care state, and a great deal of support from large and powerful corporations for its creation and expansion. Evidence about the economic implications of health insurance for businesses, including before and after Medicare, and all the way to the Affordable Care Act of 2010, indicates that the support was genuine, not strategic, and that sometimes it was critical for passage. That support calls for new thinking about how to answer the perennial question about class power in America: “Who actually governs?”

Financing the War on Cancer

We estimate the potential gains of life-extending treatments to life insurance companies and apply it to immunotherapy. These treatments promise to dramatically raise durable survival rates for a growing number of cancer patients but are often prohibitively expensive for patients and governments alike. Our main insight is that life insurance companies have a direct benefit from such treatments as they lower the insurer’s liabilities by pushing the death benefit further into the future and raise future premium income. Using detailed survival data from clinical studies, we quantify the insurers’ benefit from immunotherapy for melanoma patients. Extrapolating to 17 other cancer sites, we estimate the insurance sector’s benefit to equal $6.8 billion a year. We discuss various financing mechanisms that exploit this value creation, which depend on the relative bargaining power of insurers and consumers. Moreover, the potential gains for life insurers, which could only accrue if health insurers cover the cost of the treatments and households finance the out-of-pocket expenditure, may warrant some exploration of new boundaries between life and health insurance. We discuss the broader implications for medical innovation and long-term care insurance markets.

Nonlinear Persistence and Partial Insurance: Income and Consumption Dynamics in the PSID

In this paper we highlight the importance of the PSID in understanding income dynamics and consumption insurance. We explore the nonlinear nature of income shocks and describe a new quantile-based panel data framework for income dynamics. In this approach the persistence of past income shocks is allowed to vary according to the size and sign of the current shock. The model provides a good match with data and we confirm the results on population register data from Norway. Using the enhanced consumption and asset data in the PSID, nonlinear persistence is shown to have key implications for consumption insurance.

Emerging product-process archetypes in oncology: informing the sustainable provision of next-generation medicines

The emergence of more targeted molecular therapies has contributed to accelerated growth within the oncology market, with forecast spends expected to be circa $74-84 billion by 2018. Coupled with its many specificities around pricing, insurance implications and ethics, we argue that the segment may best inform future pharmaceutical value network design characteristics. Through exploration of future state scenarios and opportunity areas, driven by the adoption of emerging process and digital technologies, a base framework is extended to enable a systematic assessment of candidates that are representative of the wider oncology market. These include niche, low volume drugs on-patent, through to higher volume generics with a history of supply shortages. Oncology 'archetypes' are proposed - classified as 'new niche', 'old niche' and 'established generics' - and applied to develop associated models for reconfiguration, through matching emerging process capabilities to future adaptive supply requirements, and informing the potential for economies of drug 'repurposing'.

Emerging product-process archetypes in oncology: informing the sustainable provision of next-generation medicines

The emergence of more targeted molecular therapies has contributed to accelerated growth within the oncology market, with forecast spends expected to be circa $74-84 billion by 2018. Coupled with its many specificities around pricing, insurance implications and ethics, we argue that the segment may best inform future pharmaceutical value network design characteristics. Through exploration of future state scenarios and opportunity areas, driven by the adoption of emerging process and digital technologies, a base framework is extended to enable a systematic assessment of candidates that are representative of the wider oncology market. These include niche, low volume drugs on-patent, through to higher volume generics with a history of supply shortages. Oncology 'archetypes' are proposed - classified as 'new niche', 'old niche' and 'established generics' - and applied to develop associated models for reconfiguration, through matching emerging process capabilities to future adaptive supply requirements, and informing the potential for economies of drug 'repurposing'.

Risk Landscape of Autonomous Cars

This article presents a study of how automobile risks are changing over time as the level of automation shifts from the traditional to semi-autonomous to fully autonomous car. The study involves the concept of comparative advantage between the human driver and the driverless car to determine how the roles between the two have been changing and, in turn, how the change affects attendant risks. To develop a risk landscape across changes in levels of automation, the roles of human driver and driverless car are matched with the five levels of automation used to describe the phases of development of the driverless car. We conclude that the costs associated with fatal accidents will decrease sharply over time as the driverless cars are deployed on the road. And we offer implications for policy, regulation, and insurance based on our analysis of the changing risk landscape.

Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

How much are low- income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts’ subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low- income adults. As subsidies decline, insurance take- up falls rapidly, dropping about 25 percent for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower- cost, indicating adverse selection into insurance. But across the entire distribution we can observe (approximately the bottom 70 percent of the willingness to pay distribution) enrollees’ willingness to pay is always less than half of their own expected costs that they impose on the insurer. As a result, we estimate that take- up will be highly incomplete even with generous subsidies. If enrollee premiums were 25 percent of insurers’ average costs, at most half of potential enrollees would buy insurance; even premiums subsidized to 10 percent of average costs would still leave at least 20 percent uninsured. We briefly consider potential explanations for these findings and their normative implications.

Identification and estimation of landslide-debris flow disaster risk in primary and middle school campuses in a mountainous area of Southwest China

In China, school campuses are greatly affected by natural disasters such as landslide-debris flows in mountainous areas. To minimize disaster losses, it is very important to identify and assess disaster risks for every relevant subsystem. By comprehensive consideration of natural and human activities, landslide-debris flow hazard, environmental susceptibility, and exposure of primary and middle school campuses were identified in Chuxiong, a mountainous area of southwest China. These factors were assessed by applying the Analytic Hierarchy Process method and k-means Clustering Algorithm. A risk index was also proposed, and a risk map was developed based on it. The results show that hazard density and extreme precipitation intensity were the key hazard-inducing factors. The distributions of rivers, faults, slopes, and soil erosion were the key environmental susceptibility factors, and this finding is consistent with the intensive risk distribution. The increasing amounts of human disturbance, such as serious soil erosion due to farming on steep slopes, degradation of vegetation caused by changes in land use, and highway construction due to rapid urbanization, also play important roles in increasing the risk. We conclude that the environmental factors determine the distribution and intensity of the landslide-debris flow hazard risk to some extent. However, the exposure of primary and middle school campuses, including the density of schools and their contribution, leads to potential losses in landslide-debris flow hazard zones. We highlight the integrated risk assessment including hazard-inducing factors, environment susceptibility, and campus exposure. The results have practical implications for sustainable campus management, planning, and disaster insurance.

Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

How much are low-income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts' subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low-income adults. As subsidies decline, insurance take-up falls rapidly, dropping about 25% for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower-cost, consistent with adverse selection into insurance. But across the entire distribution we can observe – approximately the bottom 70% of the willingness to pay distribution – enrollee willingness to pay is three to four times below own expected medical costs. As a result, we estimate that take-up will be highly incomplete even with generous subsidies: if enrollee premiums were 25% of insurers' average costs, at most half of potential enrollees would buy insurance, and even premiums subsidized down to 10% of average costs would still leave at least 20% uninsured. We briefly consider explanations for this finding – which suggests an important role for uncompensated care for the uninsured – and explore normative implications for insurance subsidies for low-income individuals.

Pathogenic variants in the healthy elderly: unique ethical and practical challenges

Genetic research into ageing, longevity and late-onset disease is becoming increasingly common. Yet, there is a paucity of knowledge related to clinical actionability and the return of pathogenic variants to...

Investigating the Risk Reduction Potential of Disaster Insurance Across Europe

The notion that insurance can play a significant role in risk reduction has recently gained increasing attention in the wake of rising losses from natural disasters. While this notion is accepted in theory, we notice that, in practice, little is known about if and how insurance promotes efforts to lower the occurrence probabilities of an event or reduce its impacts. Direct linkages between risk reduction and insurance appear lacking in most existing insurance schemes, and the risk reduction potential is usually not a recognised aspect when designing or reforming insurance schemes. In response, multisectoral partnerships are being developed as innovative mechanisms to address this shortfall. Our analysis seeks to determine how the risk reduction linkages of insurance can be assessed and developed further in a multisector partnership (MSP) setting. We consider four methodologies applied in previous studies and explore them for several European examples of insurance development. While very different in scope and history, our examples share one common feature: they can all be considered as MSPs designed to foster greater collaboration between different stakeholders. We use those examples to act as testing grounds for the assessment of the risk reduction implications of insurance. Our findings show that the potential for risk reduction of new or reformed schemes could be strengthened through multisectoral partnerships. We conclude with a discussion of how the four methods could assist in the development of innovative responses to natural hazard insurance in a multisectoral partnership context.

The macroeconomic and welfare implications of rural health insurance and pension reforms in China

We assess the potential impact of rural health insurance and pension reforms on macroeconomic outcomes and social welfare in a dynamic general equilibrium model calibrated to the Chinese economy. We analyze transition paths as well as steady state responses to the new policies. The current reforms in China provide modest rural pensions and reimbursement of a portion of healthcare costs, but at rates that are substantially lower than are already in place in the urban sector. We investigate the potential effect of raising the rural benefit rates to those enjoyed in the urban sector. While both reforms reduce income per capita, we show that the health insurance reforms are potentially welfare improving if they are implemented in a way that leads to reduced out-of-pocket health spending. The welfare gains are driven by rural health insurance providing relief from the risk of catastrophic medical expenditures that can wipe out household savings and force long working hours. A pay-as-you-go rural pension results in a welfare gain in the short-run but welfare loss in the long-run due to the distorting effects of taxes. Despite an increase in required financing due to an aging population, the welfare impact of rural health insurance remains positive when incorporating the projected old-age dependency ratio for the year 2050. However, a pay-as-you-go rural pension creates large income and welfare losses with 2050 demographics.

Assessing Current and Future Freshwater Flood Risk from North Atlantic Tropical Cyclones via Insurance Claims

The most recent decades have witnessed record breaking losses associated with U.S. landfalling tropical cyclones (TCs). Flood-related damages represent a large portion of these losses, and although storm surge is typically the main focus in the media and of warnings, much of the TC flood losses are instead freshwater-driven, often extending far inland from the landfall locations. Despite this actuality, knowledge of TC freshwater flood risk is still limited. Here we provide for the first time a comprehensive assessment of the TC freshwater flood risk from the full set of all significant flood events associated with U.S. landfalling TCs from 2001 to 2014. We find that the areas impacted by freshwater flooding are nearly equally divided between coastal and inland areas. We determine the statistical relationship between physical hazard and residential economic impact at a community level for the entire country. These results allow us to assess the potential future changes in TC freshwater flood risk due to changing climate pattern and urbanization in a more heavily populated U.S. Findings have important implications for flood risk management, insurance and resilience.

The policy problem: the National Disability Insurance Scheme (NDIS) and implications for access to education

This paper explores the changing terrain of disability support policy in Australia. Drawing on a critical disability framework of policy sociology, the paper considers the policy problem of access to education for people with disabilities under recent reform by means of the National Disability Insurance Scheme (NDIS), which commenced full roll-out across the country from July 2016. The paper reviews NDIS reports, legislation and associated literature to consider how eligibility to scheme participation and education services are shaped, and how education is positioned in the development and implementation of the NDIS. The analysis highlights tensions that exist for people with disabilities and their families who both access the scheme and who might draw on its provision to support their education, because of the way the policy is oriented towards pathological categorisation, standardised outcomes and service delineation rather than integrated support and informed involvement. The paper concludes by arguing that despite the policy priority across Organisation for Economic Co-operation and Development countries of increasing lifelong learning opportunities, fragmented NDIS policy in Australia prevents people with disabilities from achieving this ideal.

Cutaneous changes in varicose legs with normal skin appearance

Background: In most of Western and European countries, reimbursement for the treatment of vein disorders depends upon the severity of the disease. This is currently evaluated according only to skin appearance (normal skin, edema, cutaneous changes and finally ulceration). Aim: In this study, the occurrence of skin damaging was evaluated by ultrasonography in varicose legs with apparently normal skin (excluded from reimbursement in many countries). Methods : Only legs with extensive varicose veins were considered (reflux originating from the saphenofemoral junction and descending along the great saphenous vein down to the lower leg). US findings fom the varicose leg were compared to those from the contra lateral healthy limb. Results: In 13/18 varicose legs, skin changes related to inflammation were observed: dermal edema, subcutaneous edema, dermal or subcutaneous infiltration. In these legs, scoring for venous symptoms resulted higher than in the remaining 5 legs. Discussion: Sonography demonstrated the occurrence of cutaneous and/or subcutaneous inflammation in varicose legs with apparently normal skin. These objective signs correlate to heavier symptoms and greater limitation in working, domestic and social activities. Possible forensic and insurance implications are finally discussed.

Case report of an occupational electrocution fatality: histopathological, medicolegal, work safety and insurance implications

Case report of an occupational electrocution fatality: histopathological, medicolegal, work safety and insurance implications