Most of us have been prescribed antibiotics for infections we think of as mild or trivial. However, these can become life threatening when the antibiotics needed to treat them stop working. The failure of antibiotics is already estimated to cause 700,000 deaths each year, a figure that is expected to rise to millions in just a few decades. As well as being a threat to public health, antimicrobial resistance poses a palpable risk to insurers, with direct implications extending along three main dimensions: Antimicrobial resistance, mortality risk by age and cost per case of insured illnesses, say The Geneva Association’s Ms Adrita Bhattacharya-Craven and Triangulate Health’s Mr David Tordrup and Ms Rebekka Aarsand.
Antimicrobial resistance (AMR) is one of the top 10 threats to global health. The number of individuals estimated to lose their life to resistant infections that cannot be treated is expected to rise to 10m annually by 2050 if the current trend is not reversed. The current death toll due to COVID-19 stands at around 5m in comparison. Given the low awareness of AMR in societies and issues around the availability and quality of data, current estimates may not truly reflect the extent of the crisis. Are we in danger of failing to heed the early warnings of another global public health crisis?
AMR is not a new concept. Alexander Fleming, the father of penicillin, predicted the problem as early as 1945: “The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism.”
In this forward-looking statement, Fleming not only recognised that the misuse of antibiotics would lead to resistance, but that resistance would lead to excess mortality from infection. This doesn’t just apply to the relatively narrow spectrum of ill health caused by trivially-acquired infections, it threatens the entire fabric of recent medical advances.
Pioneers such as Robert Koch and Louis Pasteur, more than 100 years ago, described how microbes are the cause of common illnesses. This revolution in understanding enabled the medical community incrementally to improve their practices and develop technologies that have enabled chemotherapy and treatments for autoimmune diseases.
However, these advances rely on the availability of effective antimicrobials, which is increasingly threatened by AMR because of ‘misuse or overuse’ of antibiotics. As such, AMR has direct implications for health and life insurers because of its impact on health outcomes and the overall cost of providing medical care. Those of particular relevance to insurers and underwriters include:
- Surgical interventions
Any surgical intervention is associated with a risk of subsequent infection of the surgical site and/or systemic infection. Today, such infections can be treated with antimicrobials, but infections are increasingly caused by resistant pathogens.
Cancer patients undergoing chemotherapy are more susceptible to infection due to immune-related side-effects. In a recent study of children and adolescents with cancer, 20% had severe COVID-19 infection and about 4% died. Infectious disease can therefore have a larger impact on children with cancer compared to the general paediatric population, so a lack of effective antimicrobials would put this vulnerable group at higher risk of morbidity and mortality from bacterial infections.
- Opportunistic infections
Bacterial infections tend to accompany other primary health complaints, such as viral infections of the respiratory tract or skin or mucous membranes. The risk of such infections is generally greater in the elderly and so inadequate treatment could increase the risk of mortality and morbidity among them.
- Healthcare-associated infections
Many bacterial infections arise from invasive, non-surgical medical interventions, such as the use of catheters, shunts or ventilators. The setting in which these infections occur may be particularly conducive to multi-drug resistant pathogens.
How big is the problem?
Globally, antibiotic consumption increased by 46% between 2000-2018, making the job of mitigating the risks of AMR even more challenging. A report from the OECD found that several types of pathogens responsible for neonatal meningitis and urinary tract, surgical site and foodborne infections are resistant to common antibiotics in up to a staggering 30-40% of cases in G7 countries.
In the US, more than 2.8m episodes of antibiotic-resistant human infections occur annually, leading to at least 35,000 deaths. In the EU, an estimated 25,000 deaths are attributed to resistant infections annually, as well as 2.5m additional hospital bed days due to morbidity, triggering a direct cost burden of around EUR900m ($1.01bn) to health systems and EUR1.5bn to society overall.
Why should insurers be worried?
The direct risk of mortality or long-term morbidity and disability resulting from routine surgery will increase with AMR, particularly for the elderly. At what point will insurers/payers and health providers have to reconsider the risk of replacing an arthritic joint due to the risk of an untreatable infection?
When will AMR sway the risk-benefit balance of cancer interventions? In the US, a 30% reduction in the efficacy of antibiotics is already estimated to claim 6,000 deaths per year from infections from just seven medical procedures. It is not clear what will happen when trivial infections turn deadly. The implications for cost inflation across the board are also significant, when harder to treat infections result in increased hospitalisation, longer lengths of stay or the use of newer and more expensive antimicrobial agents.
What can insurers do?
These facts warrant urgent multisectoral action, yet the discourse on AMR has remained all too niche in global public health and pharmaceutical research and development. The AMR Industry Alliance formed to combat this growing crisis contains no notable involvement of payers or providers from the private sector.
With up to 80% of healthcare provided privately in some parts of the world, voluntary health insurers have an important role to play in sensitising segments of this market to limit their risk exposures. Similarly, it is not clear if life insurers are factoring in the potential adverse effects of AMR on their mortality tables.
Insurer-led interventions should contain messages that can influence consumer and provider attitudes towards antibiotics simply and at scale. On the demand side, insurers are optimally placed to improve user awareness of AMR. Knowledge about appropriate use of antibiotics and the risks of AMR vary widely by country and is often incomplete.
Engaging with the insured population and sensitising insurance administrators and private providers across health, social care or old-age residential care settings are simple, effective and inexpensive starting points. On the supply side, insurers could collaboratively devise standardised clinical protocols with providers to promote rational prescribing, monitor use and integrate an ‘AMR surveillance strategy’ in any quality assurance interventions. Integrating such a strategy with the way they reimburse providers could incentivise good and deter inefficacious practice.
Failure to take action against AMR could mean that the next superbug renders antibiotics useless, resulting in an unprecedented crisis to human health and economic prosperity.
The past two years have given some insight into the devastation that can be brought about by a small, unknown pathogen. It is now timely for the industry to muster all the foresight it can and work collaboratively to avert the next big public health crisis. A
Ms Adrita Bhattacharya-Craven is programme director, health and ageing at The Geneva Association, Mr David Tordrup is director and Ms Rebekka Aarsand is business manager at Triangulate Health, UK.