Effect of a New Diagnosis of Barrett’s Esophagus on Insurance Status

Abstract & Commentary

By Malcolm Robinson MD, FACP, FACG, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. Robinson serves as a consultant for TAP, Pfizer, Janssen, Eisai, J&J-Merck, and Procter & Gamble, is on the speaker’s bureau of Janssen, Eli Lilly, Solvay, TAP, and Aventis, and does research for Forest Labs, Wyeth-Ayerst, AstraZeneca, and Centocor.

Synopsis: Although patients with Barrett’s esophagus have a normal life expectancy, diagnosis of Barrett’s esophagus more than doubles life insurance premiums and may limit or prevent access to health insurance.

Source: Shaheen NJ, et al. Effect of a new diagnosis of Barrett's esophagus on insurance status. Am J Gastroenterol. 2005;100:577-580.

Barrett’s esophagus (BE), metaplastic replacement of esophageal squamous mucosa with specialized columnar epithelium, is increasingly common. BE is clearly associated with an increased risk of esophageal adenocarcinoma, and screening endoscopies have been recommended to identify BE (and to initiate endoscopic surveillance to allow early identification of dysplasia or early malignancy). Unfortunately, direct data do not yet substantiate that such screening and surveillance will lengthen life or provide improved quality of life. Shaheen and colleagues hypothesized that identification of BE might adversely impact life and health insurability. To assess such impact, this study assessed effects of newly diagnosed BE on insurance rates from 20 insurers in California and North Carolina. In each location, a BE patient requested the best rate for a $1 million 20-year term life insurance policy with the preferred rate for a nonsmoker. After the best rate was obtained, the rate for an identical policy with the new diagnosis of nondysplastic BE was requested. In North Carolina, the patient was a 43-year-old Caucasian male nonsmoker. In California, the patient was a 36-year-old female nonsmoker. Companies refusing to insure a patient with BE or increasing life insurance premiums for this diagnosis were sent a physician’s letter including data demonstrating normal life expectancy with BE. Health insurance quotes were also requested. The mean life insurance annual premium for the healthy male was $1,255 with a range of $1,050 to $1,495. With BE, the mean rate rose 118% to $2,731 ($1,250-$4,340; P < 0.001). The healthy female premium was $517 ($452-$551), rising by 177% with BE diagnosis to $1,434 ($1,144-$1,896; P < 0.001). No company lowered its premium after physician letters requesting reconsideration had been sent. Health insurance could not be obtained at all from a number of companies, and no companies would consider issuing health insurance without additional evaluation. Shaheen et al state that 3 million Americans have BE. It is clear that most of these will never get cancer (rate of cancer developing in BE is < 0.005 cases/year). Overall 'statistical" life expectancy is almost certainly normal in BE. The authors strongly assert that insurers need to be educated regarding the generally benign prognosis of BE, and patients who are considered for screening must be told that there are some potentially drastic consequences inherent to the diagnosis of BE that may not be counterbalanced by any medical advantage provided by such identification.

Commentary

Physicians often tend to be 'activists,’ assuming that most or all possible medical interventions are worth undertaking. Unfortunately, they are also frequently motivated by the fact that intervening (as in screening endoscopy for BE) will be financially rewarding for the physician involved. In this regard, the situation may be similar to asking a barber about the utility of haircuts. This study and many others question the value of universal endoscopic screening for BE. If such screening cannot reproducibly improve quality or length of life and if there are powerful negative consequences to undertaking such screening, involved professional societies ought to re-think their current strong support for this program. At the least, it is mandatory that patient understand all of the admittedly limited benefits and the unquestioned risks of undertaking such screening. BE occasionally can be the precursor of a dreaded cancer, but most patients with BE can be expected to have a long and healthy life. As physicians, we should think twice before recommending screening of heartburn sufferers for BE. Without a doubt, the medical profession needs to help inform insurance companies that life insurance should be available to nondysplastic BE patients without huge increases in premiums. Furthermore, the loss of health insurance by patients with BE is viciously counterproductive since it may well prevent access for whatever screening and care may be needed for their long-term management.