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The role of social criteria in the prognosis

and evolution of the diseases and their

use in insurance medicine
Dr. Ioana Soare, m.d., ph.d.
Romanian National House of Pensions CNPAS
Romanian Association of Insurance Medical
Experts CMEA

In the last 30 years a new statistical, globalizing approach in

medicine has reached importance - we focus now on evidence
based medicine and on the quality of life of the patient, covering
all common aspects including health, environmental contact,
financial aspects and human rights.

The quality of life component that refers strictly to

health involves
physical, emotional and social wellbeing .

WHO: health is a state of complete physical, mental, and

social well-being, not merely the absence of disease or
functional limitations.
The most usually considered non-medical factors implied
in health, statistically speaking, are: sex, age, alcohol
abuse/smoking/lifestyle, occupation.
If the private insurers have long ago considered those as
risk factors, and acted accordingly, in disability
assessment medicine/social medicine/insurance
medicine for state insurance companies, this factors are
not yet considered.

Osteoarthritis- particularly coxarthrosis/

hip arthritis
a main health problem

Scandinavian authors determined the most important social factors

implied in the prognosis and evolution of coxarthrosis: marital
status, studies, access to medical care .
A very large study in Norway found out that risk factors for
becoming a disability pensioner with a musculoskeletal diagnosis
are female sex, old age, not being married, low level of
education, low socio-economic status, low income, working
as shop assistant, nurse aide or charlady among women,
and heavy occupations among men .
Manual work was identified as a predictor for disability
pensioning with osteoarthritis among the people employed in
Norway, 1971-1990
From further studies considering the quality of life (QOL), among
the elements worsening the evolution and prognosis of any disease
or disability are: being single, low education, rural/ living in
the countryside.
Neither the private nor the state insurers take in consideration this
risk factors. It would be high time to modernise underwriting/ risk
assessment/disability assessment and the criteria for those
mentioned before, including the social factors together with the
health/medical factors.

International Classification of Functioning, Disabilit

y and Health

Impairment in bodily structure or function is defined as involving an

anomaly, defect, loss or other significant deviation from certain
generally accepted population standards, which may fluctuate over

Activity is defined as the execution of a task or action, with its


Participation to the social life may have some restrictions.

The ICF lists 9 broad domains of functioning which can be affected:

Learning and applying knowledge

General tasks and demands




Domestic life

Interpersonal interactions and relationships

Major life areas

Community, social and civic life

ICF was designed to make international research on consequences of
disease comparable.

It favorises a bio-psychosocial approach, which can

facilitate the evaluation of
The social model of disability
holds a very different view,
believing that disability arises
from the interaction of an
individuals functional status
with the physical, cultural,
and policy environments.
If the environment is
designed for the full range of
human functioning and
incorporates appropriate
accommodations and
supports, then people with a
non-normative functional
status would not be disabled
in the sense that they would
be able to fully participate in
society- see British
cosmologist Stephen

Social security represents state assistance, primarily

a social insurance program providing social
protection, or protection against socially recognized
conditions, including poverty, old age, disability,
unemployment and others

social insurance, where people receive benefits or services in

recognition of contributions to an insurance scheme. These
services typically include provision for retirement pensions,
disability insurance, survivor benefits and unemployment
income maintenancemainly the distribution of cash in the
event of interruption of employment, including retirement,
disability and unemployment
services provided by administrations responsible for social
security. In different countries this may include medical care,
aspects of social work and even industrial relations.
More rarely, the term is also used to refer to basic security, a
term roughly equivalent to access to basic necessitiesthings
such as food, clothing, shelter, education, money, and medical

World Bank Report 2009-2010

Poverty:a certain level of material

deprivation below which an individual
suffers physically, emotionally and socially.
There are a number of methods of
determining this level of deprivation.
The state of having little or no money and
few or no material possessions.
The state of living on less than $2 a day,
according to the World Bank. Poverty can
also represent a lack of opportunity and
empowerment, and bad quality of life in

The cost and quality of housing is key

to living standards and well-beingincreasing number of homeless people.
Large and widening health inequalities
within Member States show that not all
have benefited equally from the economic
progress that delivers better health.
Ageing can bring with it new patterns of
morbidity including multi-morbidity
(multiple chronic diseases, disability

Unemployment in the EU is now at 9.1%,

and could reach 10.3% in 2010. The rate
is more than double for young workers
(20.7%) and migrants (19.1%).
The last decade has also seen the
persistence of groups of people who
remain outside or on the margins of
the labor market, often facing multiple
barriers to entry (including low skills, care
responsibilities, age, migrant background,
disability and other discriminatory factors,

Largest Migrant Group In Europe

Tribal populations
from North India
and today Pakistan
have left for
Europe in the last
1000 years- called
Sindi, Kalo, Gipsy.
They were mostly
slaves and were
bought and sold till

In Romania

500 000 to 2 million are considered now living

Between 1950 - 1970, continued forced
sedentarisation measures, banning the practice of
nomadisme and itinerant trades.
In the '80s, the national program "Integration of
the Gypsies", undertaken by the Ministry of
Interior, covered only their evidence.
On 25 April 2000, Romanian government
approved a national strategy to address the
problem of Gypsies, a 10-year program which
aimed at raising social and economic integration
in the society.

Gipsy populations add more social

factors towards chronicisation of
diseases and disability:
Low education
Lack of papers/ no identity they
cannot receive health care
Traditional occupations


A large American study on 11,905 adults with disability,

examined the relationship between disability onset and
health status.
This cross-sectional study provides population-level,
generalizable evidence of increased fair or poor health in
people with later onset disability compared to those with
disability onset prior to the age of 21 years.
They included a set of potential confounding variables: age
(as a continuous variable); gender; race/ethnicity (white
non-Hispanic, African American non-Hispanic, other nonHispanic groups, and all Hispanics); current employment
status (employed, unemployed, student/ homemaker,
retired, unable to work); education (< high school
graduate vs. high school graduate); marital status
(married, separated/divorced, widowed, never married);
and disability duration (years limited as a continuous

Age at onset of a disability, as well as the duration of the

disability, can also impact health status. Individuals who
acquire a disability later in life may be more likely to rate
their global health status in relation to their perceived
health prior to the disability and have greater difficulty
adjusting to the disability. In contrast, early disability onset
and longer duration of disability may allow greater
adjustment to the disability both in terms of psychosocial
identity development and adoption of coping strategies,
leading to higher reported general health.
The early onset group was younger on average and more
likely to be male, employed, and more educated
compared to the later onset groups.
The following variables also showed a significant
relationship with fair/poor health: age; African American
race/ethnicity; less than high school education;
divorced/separated marital status; and not currently
being employed.

State/ Private Insurance

Social factors may be more important in determining the

unemployment and disability retirement than the medical
In the state insurance companies, these factors are not
officially considered. But we work with them and we apply
them, not discriminating persons over 50 years old, single
females living in the countryside, with a low level of
education, low income.
We realize that we must make more sustained efforts to
rehabilitate them from a medical, social and vocational point
of view.
In private insurance companies, most of these factors are
considered already for a long time ago.

The modern tendencies are towards medico-social
guidelines in insurance medicine.
Prevention of disabilities:
(1) prevention of medical conditions that lead to
body function or structure limitations; and
(2) prevention of the social and environmental
conditions that stop people with those types of
limitations from being able to participate in social and
economic activities.
We must impose EDUCATION one mandatory week
insurance medicine for every student in medicine and also
for patients, through leaflets at the family doctors.
The European Year 2010 for combating poverty and
social exclusion helped by raising awareness, reinforcing
partnerships and reaching out to new actors.

Music unites all!