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MENTAL ILLNESS AND THE LTCI POLICY

2. PANEL. Dr. Bruce Margolis, Medical Director, Genworth Financial Long Term Care DivisionPeggy Murray, Director of Underwriting, Long Term Care Partners, LLPKelly Jo Lundgren, Vice President and Director for Clinical Services

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MENTAL ILLNESS AND THE LTCI POLICY

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    1. MENTAL ILLNESS AND THE LTCI POLICY Session 42: February 28, 2006 Session Producer: Kelly Jo Lundgren, Vice-President Nation’s CareLink

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    3. 3 OBJECTIVES Gain Understanding of the UW Perspectives on Mental Illness Discuss Impact of Dual Diagnoses/ Dementia/Mental Illness/Co-Morbids Learn of Prevalence in Typical Claims Population Discuss Tools and Cognitive Tests in Common Use Discuss Claims Care Planning and Chronically Ill Determination Discuss Complexities of Claims Adjudication

    4. 4 Underwriting Perspectives on Mental Illness “If You Exclude Mental and Nervous Conditions From The Contract, Then Why Are You Declining Me For Psychosis?” Intuition tells us that psychiatric co-morbidity has a direct impact on disability and recovery – but is there proof?

    5. 5 Underwriting Perspectives on Mental Illness

    6. 6 Underwriting Perspectives on Mental Illness “Depression & Disability Due to Vision Loss” Thomas Jefferson University Hospital (Journal American Geriatrics Society 40:184-186 1996) “A longitudinal study of 872 non-institutional patients >age 68 to determine the “prevalence of depression in older adults with vision impairment, and the relationship between depression and disability”

    7. 7 Underwriting Perspectives on Mental Illness “Depression Predicts Morbidity 6 Months After Coronary Artery Bypass Surgery” Psychosomatic Medicine 65:111-118 (2003) “A study of 25 male veterans undergoing CABG who scored >10 on the Beck Depression Inventory before surgery to determine “the independent contribution of pre-surgical depression to short term outcome after CABG”

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    9. 9 Underwriting Perspectives on Mental Illness “As depression severity increased, quality of life and physical and mental functioning declined, while disability increased” “Participants with chronic lung disease, diabetes, neurological disease, heart disease and chronic pain had significantly worse physical functioning and greater disability. “ “Arthritis was significantly associated with both physical and mental functioning, while hypertension and GI disease were associated with decreased physical functioning only.”

    10. 10 Underwriting Case Studies What the Underwriter approves, the Claim Department will pay….

    11. 11 Mental Illness Prevalence in Claims Populations Prevalence of Mental Illness (depression, bi-polar) in Claims Population (American Association for Geriatric Psychiatry, 2001; Late Life Depression, A Fact Sheet.) 1775 Assessments Reviewed 12% with primary or secondary diagnosis of Depression

    12. 12 Prevalence of Dual Diagnoses in Claims Population Of 1775 Assessments Looked at: 21% had diagnoses of Dementia/Alzheimer’s, of those 3.4% also had depression 18% had diagnoses of CAD, of those 11% also had depression 16% had diagnoses of diabetes, of those 11.5% also had depression 16% had diagnoses of CVA, of those 14% also had depression 14% had diagnoses of Vision Impairment (legal blind, macular degeneration), of those 11% also had depression

    13. 13 Claims Tools/Tests On-site Evaluation Passive vs Active Assessment Behaviors Questionnaire Cognitive Testing Effect of Depression on Cognitive Testing Test Effectiveness in Mental Illness MMSE (Screening for Early Alzheimer's Disease: Is There Still a Role for the MMSE? Primary Care Companion Journal of Clinical Psychiatry 2005 7:62-67) DWR

    14. 14 Claims Care Planning Factors to Consider in Plan of Care for Primary Diagnoses of Mental Illness: Safety Functional Needs Interventions

    15. 15 Claims Care Planning Safety Is the Insured a threat to health or safety of self or others due to cognitive status? Functional Needs Need to determine wants vs. needs Interventions Psych Nurse Eval and Visits? Referral to Community Mental Health Resources

    16. 16 TQ/Chronically Ill TQ Certification “Requires substantial supervision to protect them from threat to health and safety due to a severe cognitive impairment.” Of the 12% of the claimants with Primary or Secondary Diagnoses of Depression but no Dementia/Alzheimer’s diagnoses: 82% did not meet TQ for cognitive and had an average score of 27.7 on the MMSE 18% met TQ for cognitive and had an average score of 19 on the MMSE

    17. 17 Dementia and Depression Effect of Depression on Cognition Depression as a Component of Dementia Determining the Primary Issue

    18. 18 Depression and Dementia

    19. 19 Depression and Dementia

    20. 20 Depression and Cognition Cognitive Findings Attention Working Memory Visual/Verbal Memory Speed of Processing Executive Functions

    21. 21 Depression and Cognition Etiology of Cognitive Dysfunction Reduced Motivation, Drive, Concentration Alterations in Neurotransmitters Increased Cortisol Levels Structural Brain Changes

    22. 22 Depression and Dementia Depressive Symptoms , Cognitive Decline, and Risk of AD in Older Persons (Wilson 2002) 821 participants Religious Orders Study Mean age 75.4; mean education 18.2 yrs; mean MMSE 28.4; 67% female Followed up to 7 years Finding: the RR of AD increased by 1.19 for every one point increase in CES-D score.

    23. 23 Depression and Dementia Do Depressive Symptoms Predict Alzheimer’s Disease and Dementia (Gatz 2005) 766 community-dwelling seniors in Manitoba Mean age 74.5; 61.7% female Initial depression screening (CES-D) and MMMSE over 5 year period Mean baseline CES-D 6.1 495 completed study

    24. 24 Depression and Dementia

    25. 25 Depression and Dementia Does the Risk of Developing Dementia Increase with the Number of Episodes in Patients with Depressive Disorder and in Patients with Bipolar Disorder? (Kessing 2004) 18,726 with depression and 4,248 with bipolar disorder with at least one hospitalization Average age 57.5 (depression); 52 (bipolar) Female 67.4% (depression); 59.4% (bipolar) Finding: risk of dementia appeared to increase with number of depression and bipolar episodes

    26. 26 Depression and Dementia

    27. 27 Depression Vs. Dementia

    28. 28 Depression and Disability Incidence of Disability Among Preretirement Adults: The Impact of Depression (Dunlop 2005) 7922 respondents Health and Retirement Study (HRS) Age 54-65 at time of survey 7% had depression at time of survey Odds of ADL disability over two years was 4.3X greater for those with baseline depression Chronic conditions and higher-level limitation health factors explained more than half the excess disability related to depression

    29. 29 Depression and Claims

    30. 30 Depression and Claims

    31. 31 Determining the Primary Issue Mental/Nervous Exclusion - Contract Language Comorbid Conditions Functional Loss Cognitive Loss Medical Records Psych Records

    32. 32 Questions?

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