Some insurers have added the carcinoembryonic
antigen (CEA) blood test to the laboratory screening profile for Life and
Health insurance applications, and some of our U.S. clients have asked for
advice on whether to adopt this test. Every test has repercussions to consider,
and CEA is an excellent example with both positives and negatives.
The rationale for CEA screening is simple: a
good cancer-detection tool would strengthen underwriting. The only underwriting
tool that detects cancer is PSA screening in men over 50. Because of
underwriting’s limited ability to screen, cancer claims predominate in the
first five years of insurance policies. The promise of a CEA test is that some
cancers express CEA. One insurance laboratory’s research demonstrated that elevated
CEA is associated with very high mortality among insurance applicants. Although
CEA is expensive, our analysis of protective value clearly demonstrates
practical break-even points.
End of story? No. For multiple reasons, we view
CEA screening as a bad strategy. Let’s first consider the implications of
screening tests and what happens to the applicant with an abnormal result.
Implications
for Insurers
Every screening test immediately increases
acquisition cost by the price of the test. The new test creates distinctions
among otherwise identical (not tested) applicants. A test like CEA that
identifies significant mortality risk results in a declined application. Those
declines decrease premium revenue because fewer applicants qualify for
an offer.
Higher cost with lower revenue is not an
attractive business plan. Why screen at all?
The strongest argument for any screening is
avoiding anti-selection. PSA is a good example of a valid screening test
because many applicants know their PSA value, and we should know it, too. CEA
is a much different proposition. Some people will anti-select because of known
cancer or even vague concerns of ill health. You might catch them with CEA
screening, but not very efficiently. Even in colon cancer, where the
association with CEA is strongest, sensitivity is as low as 50%. That
means half of patients who have colon cancer have a normal CEA value.1
Competitive practices can create an additional
type of anti-selection. If competitors screen for CEA, the company without
similar screening gets applicants they rejected. MIB should provide protection
in lieu of matching the CEA screening strategy.
Finally, a motivation that many clients have
cited for CEA screening is to reduce mortality. Despite the increase in cost
and decrease in premium, CEA is capable of enough mortality reduction to yield
a gain on the bottom line. Lower mortality works if you maintain constant
premium and capture higher profit. If instead, you lower the base premium, you
have declined some applications that used to make sales, taken the rest at a
lower premium, and increased your acquisition cost. Can you then make enough
new sales at your lower price to come out ahead?
Implications for
Applicants
All tests create this dynamic for premium, costs
and profit. CEA screening, however, generates a wholly different repercussion
for your applicant, so potentially harmful that this alone militates against
this test.
Consider the insurer’s message to the applicant
declined for high CEA. Is it sufficient to advise a consultation with a doctor?
Should that advice mention cancer? What will you offer regarding
reconsideration? Consider also the liability and related negative press that
the insurer might create for itself with such communications.
For example, the first comment from the applicant's
physician would likely be that CEA is not an appropriate screening test and the
insurance company shouldn’t have tested it. Then the doctor would explain that
this could be cancer of the colon or elsewhere, or it could be meaningless. The
only easy out is for the doctor to repeat the test with a normal result. That’s
just a waste of time and money, plus serious loss of sleep for your client
waiting on the result of the repeat test. Confirmation of the abnormal CEA is
much worse. This will trigger an expensive, invasive and time-consuming series
of investigations including colonoscopy and multiple imaging procedures.
The only good consequence for the insurer is the
possibility of early detection and successful treatment of a potentially fatal
disease. In this case, the client can credit the insurer for a lifesaving test.
That is probably not the most common outcome. The worst-case scenario is what
makes CEA screening unacceptable clinically and should deter insurers: after
the workup, everything looks normal except the CEA. Now the message is that the
client probably has a bad disease and the doctor can’t find it. Your client can
only go home and worry until something develops, solely because of your
underwriting requirement.
All insurance tests raise some features of this
problem. Protective value studies or cost/benefit analyses mislead when the
scope is too narrow. Be sure to examine all potential repercussions of a change
in test strategy.
Endnote: https://www.ncbi.nlm.nih.gov/pubmed/26700203
.
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