Winter 2002


Screening Clients for LTC Coverage | Conclusion

Diabetes: A LTC Perspective

Diabetes is a common finding in older clients; its incidence increases with age.

  • 50% of all diabetics are over the age of 50

The question is how does a history of diabetes affect a client’s insurability for LTC insurance? The answer involves understanding how the diabetic disease process can lead to premature disability and death.

Despite the advent of sophisticated laboratory testing, over 50% of all diabetics in the United States remain undiagnosed, numbering nearly 8 million. Of those who are diagnosed, nearly 70% or 5.6 million do not require insulin (the non-insulin dependent group or Type II). The remaining 2.4 million diagnosed diabetics require insulin and are called Type I.

IMPORTANT NOTE: There is new diagnostic criterion for diabetes. The diagnostic test for diabetes is the fasting glucose test instead of the glucose tolerance test. A fasting blood glucose greater than or equal to 126mg/dl indicates diabetes. However, an abnormal fasting blood glucose test must be confirmed by repeating the test on another day.

The essential underwriting issues for the LTC carrier are:

1. How long has the client been diagnosed with diabetes?
2. What has been the degree of diabetic control since the diagnosis?
3. What are the complications from the diabetes?

From the statistics above, it is clear that the majority of diabetics in the United States are non-insulin dependent (Type II) and are adults. This proves to be good news on two counts.

First, the progression of Type II diabetes diagnosed in the adult years is not as aggressive as the insulin dependent form diagnosed at a young age. This doesn’t mean that non-insulin diabetes in an adult is not serious. It is, and it can lead to accelerated disability and death.

Second, there are fewer years for the disease to do its damage to "target organs" (i.e. blood vessels, heart, kidneys, nervous system and brain).

IMPORTANT NOTE: The longer the client has diabetes, the more likelihood of complications.

Find out the type and the age of diagnosis. It is helpful to ask how the diagnosis was made. Did the client have symptoms (i.e. fatigue, increased thirst, increased urination, weight loss)? Was it an incidental finding on a routine lab test?

Find out the treatment program. A small group of diabetics can be managed with diet and exercise alone. The majority of diabetics are put on medication. Type II diabetics initially go on oral medications. Type I diabetics go on insulin. At some point in the disease process, Type II diabetics may need to also go on insulin.

IMPORTANT NOTE: All diabetics are placed on dietary and exercise programs. Diabetics who follow dietary and exercise guidelines generally have much better blood glucose control and fewer complications. Be sure and document the height and weight of the client.

There are a number of newer oral medications for Type II diabetics. It is important to document all the medications the client is taking for diabetes as well as other medical problems. For an excellent overview of Type II diabetic medications, see this link: http://www.risktutor.com/demo/feb_99.html

IMPORTANT NOTE: Many diabetics have hypertension (high blood pressure). Hypertension only accelerates the diabetic complications unless properly treated. If your client has both diabetes and hypertension, find out if the blood pressure readings are with the normal range (140/90 or less).

Find out the degree of blood glucose control. Does the client do home monitoring? If yes, what are the blood glucose readings? Readings of 150mg/dl are good but reading greater that 150mg/dl demonstrate problems with control.

The most important test from the perspective of diabetic management is the glycohemoglobin A1-C. This test "looks back" at the degree of blood glucose control over the last 90 days. A1-C readings of 7.0 or less indicate good control. A1-C readings that are greater that 7.0 indicate less than desirable control. Readings that are 10.0 and higher indicate serious control problems. See this link for an excellent overview of the glycohemoglobin test http://www.endocrineweb.com/diabetes/control.html

IMPORTANT NOTE: Smoking accelerates diabetic complications. Clients who are diabetics and smoke are a poor risk for LTC coverage. Be sure and document the client’s smoking history.

Find out if there are any diabetic complications. The following are a list of diabetic complications:
  • Hypertension
  • High Cholesterol
  • Peripheral Vascular Disease (especially in the legs)
  • Retinopathy (small vessel disease of the eyes)
  • Nephropathy (disease of the kidneys)
  • Neuropathy (disease of the nervous system)
  • Cardiac disease (heart attack, angioplasty, bypass, etc.)

Document when the complications occurred and how they are being managed (i.e. medications, surgery, etc.).

Diabetic complications carry with them significant disability and mortality. More than 190,000 Americans are in nursing homes with a primary diagnosis of diabetes. This represents 15% of the nursing home population.

Find out physical activities, limitations and lifestyle. It is important to know the clients functional status relative to the diabetes. Does the client exercise? Does the client drive? Are there any limitations? Do other medical conditions limit the client’s functional capabilities?

IMPORTANT NOTE: Clients with functional limitations, significant complications and poor blood glucose control are not insurable for LTC coverage.

Diabetics, especially Type II diabetics, are insurable for LTC coverage. In many cases, that can be issued at standard rates. By using the above screening protocol, the LTC representative will be better prepared to identify which clients are insurable. It will also spare inappropriate LTC candidates from the underwriting process, which is both costly, and time consuming to the representative and the LTC carrier.

© Copyright 2001, RiskTutor Inc.