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Background and Objective: Empirical data, representative of the total population, are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients who are covered by statutory health insurance with regard to age and distribution of care levels when in home or institutional care with a special focus on whether rehabilitative care was performed., Methods: The data of 88,575 LTC patients were analyzed longitudinally for 10 years, using routine data analyses on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221,625 observation years). The numbers of LTC patients and their care levels while in home or institutional care were calculated, as were any changes to another care level or discontinuation of LTC benefits (as a result of the need for care falling below the eligibility criteria for care leveI or to death) during 1-10 years after the onset of LTC, always with respect to whether rehabilitative care had taken place or not. For the evaluation of care factors an indicator was developed., Results: Total mortality was found to decline and reactivation to increase considerably for LTC patients after rehabilitation, basically irrespective of their age or care level and in home or institutional care settings as well. Ten years after the onset of care, 30.7 % of the patients with rehabilitation were still in nursing care, 9.8 % were reactivated and 59.5 % deceased. In contrast, only 9.2 % were still in nursing care, 3.7 % reactivated and 87.1 % deceased without rehabilitation. These results are irrespective of age distribution, care level, and residence in home or institutional care settings. The care status of patients, measured by the percentage in reactivation, care level I-III, and death, substantially depends on age at onset and care level and in addition on rehabilitative procedures. Hypotheses for further research are outlined., Conclusion: Rehabilitation has a clear-cut potential for life extension as well as reducing or detaining long-term care if applied to (LTC) patients. The group of rehabilitated LTC patients has a comparatively higher degree of reducing or resolving LTC up to a complete reactivation or prolonging of life in spite of care needed. A successful rehabilitative effect occurs over all age groups and all care levels during home care considerably as well as during institutional care to a lower extent. Differentiation between the age at onset of LTC, care level, and first year and follow-up mortalities is recommended as well as between rehabilitated and nonrehabilitated care patients when undertaking medico-actuarial calculations.

Background and Objective: Empirical data, representative of the total population are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients with regard to age, gender and distribution of care levels when in home or institutional care., Methods: The data of 88.575 long-term care patients were analysed longitudinally for ten years, using routine data on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221.625 observation years). The numbers of LTC patients and their care levels while remaining in home or institutional care were calculated, as were any changes to another care level or discontinuation of long-term care benefits (as a result of the need for care falling below the eligibility criteria for care level I or to death) during 1 - 10 years after the onset of long-term care., Results: Total mortality was found to increase with age and care level in homecare as well as in institutional settings for both sexes. It is greatly influenced by the first year mortality, which for both genders was lower for care level 1 in home care settings but higher for care level 2 and much higher for care level 3 than in institutional care settings. Follow-up mortality (second to tenth year after the start of LTC) was lower for care level 1 and 2 in home care settings than for institutional care. But for care level 3 the follow-up mortality was conversely higher in home care settings than in institutional care (for both genders). The number of patients returning to an active life after rehabilitation is much higher for home care patients than those who had been in institutional care. The transfer rate from homecare to institutional care increased during the first three years after onset of care, descending thereafter, and was much higher than conversely., Conclusion: The slogan "outpatient care before inpatient care" must be differentiated and considered carefully with regard to the character and constellation of diseases, age attained, length of time after onset of care, care level, potential for resuming an active life, as well as level of compensation and number and nature of activities of daily life together with being given the necessary help when choosing between homecare or institutional care. Differentiation between first year and follow-up mortalities is recommended when undertaking medico-actuarial calculations., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: It was the aim of this study to estimate effects of depression on permanent disability and death in a statutory health insurance population., Methods: Data from 128,001 clients were used with a mean follow up of 6.4 years. Excess risks were calculated with Cox regression models adjusted for age, gender, education and job classification., Results: Outpatient treatment for depression was associated with an elevated relative risk for permanent disability, but inpatient treatment even more so. Life table analysis suggests higher risks of early retirement for males who get ill early in life. Depression treated solely in an outpatient setting may be associated with lower mortality early in life, but this was only significant for women., Conclusions: Outpatient treatment should include an emphasis on occupational functioning, but also a gender-specific approach is needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To bring the data from the Federal German Health report about work disability and pensioning into context with current knowledge about the course and etiology of depression., Methods: The report data about first-time recipients of a disability pension were analysed by year, illness and gender. Resulting data were interpreted and were compared with international publications., Results: The percentage of applications for disability pensions due to psychiatric illnesses have been rising steadily for two decades. Among these, depression (31%) and neurotic disorders (23%) are most frequently responsible, while most other causes of disability have been declining. Current treatment of depressive disorders does not seem to have had any effect in terms of reducing the number of disabled persons per year., Conclusions: Although the risk factors associated with developing a depressive disorder have been extensively studied, data explaining the progression into disability is scarce but essential. More research in the psychodynamics of depression and work participation might be helpful.

Unlabelled: From the period of September 2000 to March 2006 Hannover Reinsurance and the Department of Traumatology of the Hanover Medical School conducted a retrospective observational study of the long-term outcome of patients after polytrauma. The follow-up period was on average 17 +/- 5 years. The goal of the study was to determine the social, financial, medical and psychological long-term outcome after a severe accident. Of the 1560 enrolled patients 519 patients died in the observed period, 397 patients were followed up but could not be examined, 637 patients (female n = 158, male n = 479) were examined and answered detailed questionnaires concerning their social, financial medical and psychological situation. 6 patients did not fullfil the input criteria and one patient had two polytraumata. The average age at the time of accident was 26.5 years (+/- 12.3)., Results: Financial losses were observed in 41.1% of all males and 44.4% of females. 21.7% of all male (female 18.4%) had no financial protection at all. Due to the accident 30.1% of all men were unemployed and 19.8% permanently disabled (women 27.4% and 27.6% respectively). Psychological treatment almost doubled after discharge from rehabilitation centres. Even 20 years after the accident extra-mortality was substantially increased by 79%., Conclusion: Ten to twenty years after polytrauma significant financial, social and medical impairments are still present.

The key objective of insurance medicine is the scientific based assessment of long term prognosis of a single person with respect to mortality, morbidity and disability. This is always determined in comparison to the standard population or an ideal standardised population. The evaluation of morbidity, mortality and disability is always linked to certain insurance products such as life insurance, disability cover, health insurance or derivates of these products. Additionally, insurance medicine creates the claims evaluation guidelines which are in accordance with established classifications and guidelines of other medical associations. Due to different and various reasons, insurance medicine in Germany has shown substantial deficits in the past years and decades, mostly in the areas of methodology, scientific basis, guidelines and quality control. In order to meet future challenges specific to this industry such as demographic change, longevity and new insurance covers, the discipline of German insurance medicine requires some reorganisation.

Active and successful management predominantly depends on good and trustful cooperation between the claims manager, the field representatives of the administration and the injured or damaged person. Only the early assessment and prompt and purposeful claims handling can minimize the risk of an unexpected claims development. In the early stage, particularly probands with acute psychological maldevelopment can still be helped effectively. The introduction of an adequate therapy is beneficial to the afflicted person and at the same time lowers the final developing costs. As early as in 1918, Horn stated that the early occupational reintegration, apart from granting compensation, positively affects the process of the psychological disturbance. In general, no substantial restriction on the quality of life occurs if the injuries of a physical and mental type have been treated successfully and if occupational reintegration has taken place. However, if a continuous performance loss remains in occupational life due to a chronic psychological disturbance and if the damaged person does not achieve his/her ability to work again, even the contribution of high compensation payments does generally not improve the quality of life.

Disability is a well known and tragic event for children. While adults are an established group for specific disability insurance cover, children were often neglected in the past. Although parents, organizations and paediatricans are aware of the risk, children specific incidence rates for disability are hardly available. The only sufficient source for some statistical data are the accident statistics because they represent a substantial group of specific cause related disability for children. Incidence rates for disease related chronic severe impairment or disability in children are either derived by single disease research or actuarial calculation of the German Social Disability Registration. Based on this statistical background, an extended accident insurance for children was introduced in Germany covering both accidents and disabling diseases. The key limitation for all variations of this insurance are exclusion clauses for congential diseases and mental disorders. This insurance requires a new approach in underwriting of the health risks. Because of the substantial number of impaired children, a simple decline of substandard cases are unacceptable. The early experience or medical underwriting shows predominantly health impairments of the following types: allergies, bronchial asthma, ectopic eczema (neurodermitis), disorders of speech and articulation, vision disorders and mental impairments. The suggested solution for underwriting of substandard risks is the predetermination of the possible future maximum degree of disability. The need for underwriting guidelines is supported by the market impact of the new disability cover with thousands of insurance policies issued in the first month after introduction.

The BMI system meets in an ideal way all requirements in the underwriting of over- or underweight. It is easy to handle, widely applicable and accurate. Its validity has been proved by several studies. Furthermore, it is the leading system for the evaluation of weight in all epidemiological studies. By using the BMI System, the advantages of clinical studies dealing with the prognosis of overweight can be easily introduced to the field of insurance medicine. In wide ranges, the mortality rates given by the BMI system match those of existing guidelines. On the other hand, the more favourable rating for women and older aged people leads to substantial advantages. The extramortality rates introduced by this article can be readily incorporated into automatical rating systems. Thereby, a risk assessment on the preselection level is made possible. By taking cardiovascular risk factors into proportional consideration while assessing the extramortality of overweight, it is possible to increase the accuracy and speed of the underwriting process.

In the German disability insurance, exclusion clauses are the dominating approach to the underwriting of low back pain. This is due to a lack of clear prognostic factors, the nonexistence of severity classifications and the strong impact of individual and psychological circumstances. Considering various clinical, individual and psychological indicators, a new system is introduced to allocate the prognosis of lower back pain to four levels of severity. This approach makes it possible to use extra ratings instead of exclusion clauses of mild and moderate low back pain.

Various long-term prospective studies evaluated subgroups of patients obtaining benefits of prognosis and life quality by undergoing CABG (coronary artery bypass grafting). Early and late graft failure was a recurrent problem. A significant reduction of early graft occlusion was possible by using platelet inhibitory drugs or anticoagulant therapy while IMA grafts showed an excellent long-term patency preventing late graft failure. Additionally IMA grafts improved life expectancy and reduced the risk of myocardial infarction. Although the number of high risk patients and emergency procedures increased the over all mortality rate decreased.