Preston Buzz

CH. 1

How the fundamental principles and inherent challenges of freediving embodies who we are.
Does Access To Health Care Promote Longevity?
by Jamie Wells, M.D.
June 13, 2019

The public forum is dominated by discussions surrounding access to medical care. In part, calls for expanded “health care” abound with the term often a misnomer. There is no doubt that modern medical advances extend life and cure or make chronic diseases that once held little hope possible. This progress restores individuals to their baseline if not better. Methods for prevention are also amplified and monitored. But, a new study in the Annals of Family Medicine suggests the lion’s share of curtailing or curbing premature death in a population may not rest with sick care (or “health care”) alone, but instead with behavioral factors.

The researchers found their data “produced estimates ranging from 0% to 17% of premature mortality attributable to deficiencies in health care access or delivery. Estimates of the effect of behavioral factors ranged from 16% to 65%.”

In an effort to clarify an age-old argument over where investments should be deployed to make the most positive contribution to population health and life expectancy, researchers decided to “review 4 different estimates of the contributions of health care to premature mortality and other health outcomes.” Resources are often considered best directed to medical services. But, that is only one piece of the story, as much evidence shows how influential social determinants of health are to outcomes and promoting longevity.

To understand what actually is incorporated into this concept of premature mortality, consider, for example, a fatal motor vehicle accident where excessive alcohol intake was the cause. Or, death from lung cancer due to cigarette smoking. These eventualities would be categorized more by behavioral factors. There is much work done on trying to link variations in health care use with morbidity and mortality, and debate surrounding how to direct resources tends to focus on medical services when any number of avenues warrant attention. The investigators here sought to determine how much the prior data collected on this topic actually does or does not tell us about the weighted contribution of health behaviors (eg tobacco use, poor diet, sedentary lifestyle, substance abuse), medical care albeit access to it or level of its quality, environmental exposures (eg toxins, air quality), or socioeconomic influences (eg income, support structures, safety of community, education) when it comes to health outcomes.

There are many more estimates that have made their way to the literature over the years. So, more exists than was examined in this work. It is a monstrous challenge to assess the effect of medical treatment in this manner and the limitations to doing so abound. For instance, stratifying by disease state will be more beneficial to understanding the genuine impact of a therapy than one number for an entire population’s life expectancy. As poignantly evidenced by the authors,

“For example, successful treatment of women with cervical cancer could add 21 years to the life expectancy of a particular patient. The condition affects about 13,000 women annually, therefore the estimated gain in total US population life expectancy for treatment of cervical cancer is only 1 week. Similarly, successful treatment of colorectal cancer could add 12 years of life to as many as 155,000 adults. But on a population-wide basis, it contributes only about 1 week to average life expectancy. Likewise, treatments for appendicitis, pneumonia, and influenza, although successful for many individuals, on average have a negligible effect on population life expectancy.”
So, understanding that even life expectancy as a term has refined meaning when put into context is critical to its actual interpretation. This is why comparing countries by infant mortality rates is also an incredibly flawed endeavor. For example, some countries define it differently and include first breath, while others do not. Some track till the first year, others do not. The notion it is a uniform, standard value is a false premise.

Here’s the rub. When it comes to longevity, in general, and metrics like life expectancy, they are often flawed and idealized. What benefits a population or the aggregate, may not be in the best interest of the individual as there is tremendous variability in genetics, disease, clinical status and beyond. Practicing medicine offers unique insights into how people manage risk. Intellectually, for most, knowing that 90% do well following a particular path is calming until you fall into the 10% group. Then, that potential for poor outcome becomes 100% to you. And, the meaning shifts dramatically. This is why making sweeping generalizations rarely moves the needle in improving health care delivery. Understanding the nuances of geography, populations, medical histories, behavior, biopsychosocial spheres etc is essential to compelling genuine change for the better - and for the most people.

One thing is clear, to say a population’s life expectancy rates are exclusively correlated with the availability and quality of healthcare services is overly simplistic and does not begin to address the complexity of factors involved. As inconvenient as it is, the multifaceted nature of what contributes to overall longevity is unique to individuals within a population and can have much variability by region, genetic influences, occupation, lifestyle, clinical status, education and so on.

This report’s analysis conveys “social and behavioral factors account for a much higher percentage of the variation in premature mortality than health care does.” Now, that doesn’t mean that investing in health care isn’t worthwhile. Don’t forget, these metrics don’t emphasize or address new treatments and modalities that are extending life and converting once ominous disease to more chronic conditions. There is great value in funding research and optimizing health care delivery. This piece simply reminds us that there is also value to consider that extends beyond the hospital bed and exam room. Also investing in communities and social determinants of health will improve quality of life in a multi-prong fashion, and this, too, can yield great dividends to a population - in daily life and in terms of longevity.

The take home message of this study is to diversify. Recognizing access to and the quality of medical services is one crucial component to enhancing longevity is important - especially for the individual. Factoring in the others adds value too.

On Trend

This publication reinforces (and rides the current wave on) the importance of social determinants of health already underway.

For instance, in the not-so-new realm of nontraditional health coverage, the Centers for Medicare and Medicaid Services (CMS) is expanding their Medicare Advantage plan to include benefits that meet patients “unique health needs” and improve “their quality of life.” Behavioral economics is currently in full swing and now being put to the test by this recent roll out set to take effect this year. Based on the premise that social determinants can drive poor health outcomes and increase costs, equalizing these factors through non-emergent medical transportation (NEMT, read here) as a means to reduce barriers thereby improving care access, providing air conditioners for high risk populations and specific foods for those with diabetes could impact healthcare spending with a hope of yielding overall savings. Read more here and also learn about spending by other countries on social services compared to the United States.


Robert M. Kaplan, PhD and Arnold Milstein, MD, MPH. Contributions of Health Care to Longevity: A Review of 4 Estimation Methods. Ann Fam Med May/June 2019 vol. 17 no. 3 267-272. doi: 10.1370/afm.2362, see here.


The authors are from Stanford University School of Medicine's Clinical Excellence Research Center (CERC). I recently attended a conference (unrelated to this journal article) in Chicago organized by Stanford's CERC on "Reducing the Cost of Great Care: Pathways to Value."

Originally posted May 22, 2019 on

SSA Brings Out Its Dead
The Social Security Administration plans to release an additional 694,959 historical death records.
by Donna Horowitz
May 21, 2019

The Social Security Administration plans to release an additional 694,959 historical death records contained in the Death Master File.
The release of the records to subscribers of the database, including members of the life settlement market who track deaths of insureds on policies, is set for April 27, according to the National Technical Information Service of the U.S. Department of Commerce.

The new records will be in addition to the normal weekly death-record update, a Thursday, April 25, announcement from John Hounsell, program manager with the Office of Program Management with the NTIS in Alexandria, Va., said. "SSA continues to be actively engaged in an initiative to improve our death data. As a part of this initiative, in fiscal year 2019, SSA will add nearly 3 million death records to the full and publicly available Death Master File (DMF) over the course of several months," the announcement stated. "These records are deaths currently maintained in our records that we determined should be included in the DMF."

The Social Security Administration also said the effort to update the Death Master File may result in an increase in the volume of death records received by subscribers.
It said these historical records might include more zeroes in the date of death field, which generally occurs on older records because the agency previously didn't require a valid date of death. It said the zeroes could indicate that information was missing in the death report or, in the case of paper records, was illegible when the information was put in the database.

"Sharing these deaths will increase the accuracy, integrity, and completeness of our records as well as the DFM," the announcement also said.
Servicers in the life settlement market use the Death Master File as one of its resources to track deaths of insureds on policies so they may know when to seek death benefits from insurance companies. Life expectancy providers also use the information to measure the accuracy of their forecasts on deaths.
The Death Master File contains 91 million names of deceased people that have been collected since 1938.

Originally posted 4/25/19

by Preston Ventures
APRIL 8, 2019

Free diving is a skill we have chosen to practice as a team. We chose free diving because it is not only physically but also mentally challenging which is in line with our company mantra this year of intentional personal growth. In particular free diving teaches mental strength which is a skill we use every day at Preston when digging into the data to find and develop solutions.

Free diving requires one to stay calm and breathe slowly in the face of a daunting and potentially stressful descent. For our team, this included depths of up to 66 feet without supplemental oxygen. By practicing this discipline, a person can reach depths beyond their expectations. That was what our team experienced in our checkout dive at Catalina island, with many of us exceeding our own expectations. We are also getting to apply these skills of patience and perseverance to our daily challenges at Preston Ventures.

In the coming months, Preston will publish a series of videos featuring the freediving event and discussions with Preston team members and leaders. Our entire office was able to train for and experience free diving firsthand. We undertook this adventure part as team-bonding but also as a part of our commitment to each other this year to become better people: mentally, emotionally, intellectually, or physically. We are excited to share this story. Please check back soon for the next in the series.

FRIDAY MAY 3, 2019

Guillaume Néry is a world champion freediver. He grew up in Nice, France, and started freediving at the age of 14. By the time he was 19, he set a French constant weight national record by reaching 270 feet—which, by the way, matched the world record at the time.
Then, in 2004, he set a world record in Reunion Island by diving to 315 feet. Unbelievably, a year later he reached 328 feet during a training session. He’s been breaking records for nearly his entire career. While all of that is impressive, the world that has become Néry’s second home is not something most people can really wrap their heads around. That’s because the world that lies beneath the surface of the ocean is not a place we’re meant to be. The film you see above is a testament to that.
Filmed by Julie Gautier while freediving as well (and also happens to be married to Néry) and scored beautifully, it shows Néry gliding beneath ice sheets, walking on the ocean floor with spearfisherman, and swimming with whales. It was shot all over the world; France, Finland, Mexico, Japan, and the Philippines all starred as a backdrop for one of the most incredible freediving films we’ve ever seen.

May 9, 2017

(CNN)Life expectancy at birth differs by as much as 20 years between the lowest and highest United States counties, according to new research published Monday in the medical journal JAMA Internal Medicine.
Dr. Christopher J.L. Murray, lead author of the study and director of the Institute for Health Metrics and Evaluation at the University of Washington, estimated life expectancy for each US county from 1980 through 2014. Murray and his colleagues analyzed county-level data and then applied a mathematical model to estimate the average length of lives.
Life expectancy at birth increased by 5.3 years for both men and women -- from 73.8 years to 79.1 years -- between 1980 and 2014, Murray and his colleagues wrote. During that time period, men gained 6.7 years, from 70 years on average to 76.7 years, while women gained four years, from 77.5 years to 81.5 years.

But the numbers aren't the same everywhere. Looking at the finer details, Murray and his colleagues calculated a gap of 20.1 years between US counties with the lowest and highest life expectancies.

The counties with lowest life expectancy are located in South and North Dakota, while counties along the lower half of Mississippi, in eastern Kentucky, and southwestern West Virginia also showed lower life expectancies compared to the rest of the nation. The North and South Dakota counties include Native American reservations.

At the other extreme, residents of counties in central Colorado can expect to live longest, Murray and his colleagues said.

'Drastically different life expectancies'
While the study does not directly answer why we see low or high life expectancies in specific counties, it does look at what factors contribute to the overall gap between some counties, said Murray.
"We can see that many of the counties with very low life expectancies in the Dakotas, like Oglala Lakota County in South Dakota, overlap with large Native American reservations including the Pine Ridge and Rosebud reservations," said Murray.

Conversely, Summit County, Colorado, ranked as the county with highest life expectancy in 2014 at 86.8 years, is home to several ski resort towns.
"For both of these geographies, the drastically different life expectancies are likely the result of a combination of risk factors, socioeconomics, and access and quality of health care in those areas," said Murray.
Yet, socioeconomic factors are not everything, said Murray, explaining that "60% of the differences in life expectancy across counties can be explained by socioeconomic factors alone" yet that leaves a "substantial amount of unexplained differences."
"Behaviors like smoking and physical activity, along with risk factors like obesity and diabetes, are also very important," he said.
Still, almost all counties throughout the nation showed improvement over time, though the number of additional years varied across the nation. Counties in central Colorado, Alaska and along both coasts experienced larger increases than most other counties. Meanwhile some southern counties in states from Oklahoma to West Virginia experienced either no improvement or very little over time.
The most positive note is that, over the study period, all counties show declines in the risk of early death for children under the age of 5 years old, say the authors. And, nearly all counties (about 98%) show declines in the risk of early death for people between the ages of 5 and 25, as well as those between 45 and 85.
However, people between the ages of 25 and 45 show an increased risk of death in 11.5% of counties over the study period.

'A gap of 20 years ... is absurd'
For the first time since 1993, US life expectancy in 2015 dropped significantly for the entire population, not just certain groups, the Centers for Disease Control and Prevention reported in late 2016. CDC researchers warned that a one-year shift does not mark a trend.
Ellen Meara, a professor or health economist at the Dartmouth Institute for Health Policy and Clinical Practice, said many factors impact life expectancy. She was not involved in the new research.
"Socioeconomic factors like education and poverty can shorten lives of individuals, and it may be bad to live in areas with high rates of poverty and less educated adults," said Meara. "Similarly, sedentary lifestyles (which are reflected in obesity rates) and smoking are two of the biggest individual risks of poor health and premature death. For people who develop a disease like diabetes or hypertension, also measured in the study at the county level, risk of death is higher."

Meara noted that the authors used "rigorous methods" to gain a more "comprehensive look" at deaths by county and age group. "This research echoes what we have been learning from studies in other settings over the past decade," she said. "Disparities in mortality have widened over time."
Still, understanding differences across geographic areas can provide clues, said Meara, about what might contribute to improvements over time.

"To have a gap of 20 years in a country as wealthy as ours is absurd," she said.
Murray agrees. "The inequality in health in the United States -- a country that spends more on health care than any other -- is unacceptable," he said. "Every American, regardless of where they live or their background, deserves to live a long and healthy life."

Transamerica Loses Effort to Dismiss Rate Hike Case
The suit was brought by Alberta Investment Management over 11% to 100% cost-of-insurance rate increases.
by Donna Horowitz
April 18, 2019

A federal court judge has refused to dismiss a lawsuit brought by the Alberta Investment Management Corp. over a cost-of-insurance rate increase by Transamerica Life Insurance Co.
The firm's two entities, LSH Co. and LSH II Co., and its securities intermediary, Wells Fargo Bank NA, filed a breach-of-contract suit in November in the U.S. District Court for the Central District of California in Los Angeles.

On Wednesday, March 20, Judge S. James Otero largely sided with the plaintiffs, saying four claims could remain the case and they could replead two others that he dismissed.

The Edmonton, Canada-based pension fund manager also filed a similar suit last March against AXA Equitable Life Insurance Co. in U.S. District Court for the Southern District of New York in Manhattan.
Alberta Investment Management said the increases on its 22 Transamerica policies at the center of the dispute range from 11% to 100% and ultimately would increase premiums by up to $18 million through policy maturities.

The suit said the increases were imposed on 20 of the policies in 2015 and 2016 and against the remaining two last year.
The pension fund manager said the universal policies range in face amount from $1 million to $11 million and were issued between 1985 and 2005.

The pension fund's two Luxembourg entities alleged that raising the cost-of-insurance rate, referred to in this case as the monthly deduction rate, would force them to pay exorbitant premiums that would reduce the value of the policies or force them to lapse or surrender their policies and forfeit the premiums they or their predecessors had paid for years.
They argued that Transamerica stood to gain "a huge windfall" either through higher premiums or retaining premiums on policies it would never have to pay a death benefit.

The complaint alleges breach of contract, breach of the implied covenant (contractual), breach of the implied covenant (tortious), injunctive and restitutionary relief under the California Business and Professions Code, violation of the Illinois consumer fraud and deceptive business practices law and declaratory relief. The plaintiffs are asking for compensatory and punitive damages to be determined at trial, pre- and post-judgment interest and the costs of the suit, including reasonable attorneys' fees and restitution.

In its 23-page decision, the court denied Transamerica's motion to dismiss the complaint for lack of personal jurisdiction and failure to state a claim under which relief can be granted under federal rules. The judge said the breach-of-contract claim survived dismissal. The plaintiffs argued that Transamerica breached the policies' terms by increasing the monthly deduction rate based on factors other than the insurer's expectations of future costs.

The LSH entities said the insurer breached the contract by attempting to circumvent the guaranteed minimum crediting rate and by increasing the monthly deduction rate to recoup past lost profits. The judge noted that key policy language says any change in the monthly deduction rate must be prospective and subject to the insurer's expectations of future costs factors. Such factors can include mortality, expenses, interest, persistency and applicable federal, state and local taxes.

The judge said that the plaintiffs contend that "interest" can only refer to interest that the insurer earns or expects to earn on its profits from providing insurance and not on funds in the policyholder's account. Furthermore, the plaintiffs believe that the insurer can only consider interest it earns on the mortality component in determining the cost of insurance.
"The Court concludes that Plaintiffs do not make a sufficient showing that there is a special meaning given to the term 'interest,'" Otero stated. "This does not mean, however, that the Court dismisses Plaintiffs' Breach of Contract Claim. While the Court agrees that the LSH Policies are not reasonably susceptible to Plaintiffs' interpretation of 'interest,' Plaintiffs' additional allegations allow Plaintiffs' Breach of Contract Claim to survive dismissal," the judge ruled.
Otero also said the plaintiff's contractual breach of implied covenant partially survived dismissal.

Transamerica contends the claim is barred for the policies issued in Illinois, Michigan and Illinois because those states don't recognize that claim as a valid cause of action. The court agreed with the insurer for policies issued in those states, it but allowed the plaintiffs to amend the case on this point. The judge kept in the case the claim for the remaining policies issued in California, Arizona, Washington, D.C., Florida and Nebraska.

The judge also allowed the following claims to remain in the case: tortious breach of implied covenant and injunctive and restitutionary relief under California's unfair competition law.
However, it dismissed the Illinois consumer fraud and deceptive business practices claim brought by plaintiffs, which alleged the monthly deduction rate was done to intentionally cause policies to lapse and create a windfall for the insurer.
Although the plaintiffs' alleged wrongful conduct due to the monthly deduction rate increases, they failed to allege that any of the relevant conduct occurred in Illinois, the judge said. Again, however, in dismissing this count, Otero said the plaintiffs could amend it.

The judge also held that the plaintiffs' declaratory relief claim survived dismissal. They sought a declaration that the rate increases were improper and that any excess premiums must be returned.
The suit said that "Transamerica neither has experienced, nor reasonably can expect to experience, higher mortality rates, lower investment income, or other adverse changes in expenses for its policies, including the LSH Policies."
The suit said that mortality rates have steadily improved each year since the LSH policies were issued.
It said the trend showing improved mortality is even more pronounced for older insureds in both the 2008 and 2015 Valuation Basic Tables.

Attorneys with the McDowell Hetherington LLP law firm in Houston and Hinshaw and Culbertson LLP in Los Angeles, who represent Transamerica, were not immediately available for response.
Daniel Goldberg and Avi Israeli, attorneys with the Holwell Shuster & Goldberg LLP law firm in New York, represent the plaintiffs.

Originally posted on March 25, 2019

Indexed universal life insurance sales continue hot streak
Sales broke a record last year despite rules that observers believed would slow them down
by Greg Iacurci
March 15, 2019

Insurers sold indexed universal life insurance policies at record levels last year as consumers sought a measure of protection from stock market volatility and more insurers offered product.

Indexed life insurance sales of $2.1 billion last year bested their previous record, set in 2017, by 11%, according to Wink Inc., a market research firm. (The indexed life insurance category includes both indexed universal life and indexed whole life insurance, but overwhelmingly skews toward the former, which represents 99% of the available indexed products.)

IUL sales have shot up noticeably over the past decade, following a similar trajectory to their indexed-annuity cousins. In 2008, insurers only sold $539 million of indexed life insurance, according to Wink.

"Indexed universal life has been growing pretty strongly over the past decade," said Karen Terry, assistant managing director of insurance research at Limra, an insurance industry group. "It's been with few exceptions the hot product in the life insurance industry."

IUL is a type of universal life insurance that offers an insurance benefit paired with a cash account that can be used to pay policy premiums. In an indexed product, the cash portion is tied to a stock market index like the S&P 500. Insurers credit interest to consumers based on market performance; interest is capped on the upside, but insurers can't give less than 0% interest in the event of a down market.

Advisers and consumers turned more to indexed universal life last year amid the volatility that seized the stock market late in the year and pushed the S&P 500 to its first down year since the 2008 financial crisis, said Sheryl Moore, the head of Wink Inc.

Investors also have turned away from fixed universal life insurance products in favor of IUL, given the potential to earn a higher return, Ms. Moore said. Fixed UL policies are crediting an average 3.5% today, Ms. Moore said, while investors on average have the opportunity to earn up to 11% with an IUL policy.

IUL represented 66% of all universal life insurance premiums last year, a proportion that bests all previous years, according to Limra.

Companies have also pivoted away from other forms of universal life insurance because IUL is more profitable for them and easier to sell because of its marketing pitch — downside protection with upside potential — Ms. Moore said.

Whole life insurance, however, remains the industry breadwinner, comprising 35% of overall life insurance sales last year versus 24% for IUL, according to Limra.

In 2015, the National Association of Insurance Commissioners issued a rule — Actuarial Guideline 49 — to tamp down on overly rosy insurance illustrations that life insurers used to sell products to consumers. Critics say the rule didn't curb the practice. Now the NAIC is revisiting the issue and contemplating an update to AG 49, which could negatively impact sales.

Originally posted on

Data and analytics tools are “ultimately helping insurers make better, faster decisions”
by Alicja Grzadkowska
March 06, 2019

The use of data and analytics in insurance is bringing big changes to the industry. While insurance has always been driven by data, the sophistication of today’s analytical and machine-learning models is allowing insurance companies to begin reaping the rewards of the big data evolution, according to Insurance Nexus. For one, this power couple is changing risk exposure assessment and claims operations, one expert told Insurance Business, though that’s not the only upside of data and analytics.

“This digital transformation has enabled the insurance industry to form a better understanding of customer expectations, and design more tailored products and services for customers. The industry can now use these insights to improve and better inform risk exposure management, friction-free claims experience, and accelerate underwriting operations,” said Govind Balu (pictured), AXIS Capital’s newly appointed chief analytics officer, who was most recently chief data and analytics officer for Allstate Roadside Services.

The specific uses of digital and data-focused solutions that have proven to be especially useful to insurance firms have a common theme, in that they are putting better tools and insights into the hands of industry professionals and in turn, helping them make better decisions, according to Balu.

“For example, machine learning (ML) and artificial intelligence (AI) techniques are increasing automation, and accelerating underwriting and claims operations. These techniques help better understand risk exposures, can quickly convert various unstructured data inputs, such as emails, policy documents, and claims records, into structured and digital formats, so that underwriters and claims teams can make decisions in real-time, looking at submission materials in a sensible order,” he explained. “This allows more time for professionals to do the jobs in which they are highly skilled, rather than using their time to wade through information.”

Analytics also come in handy when building pricing algorithms, which means quotes can be provided in real-time, thereby making the insurance-buying process that much more efficient for brokers and their clients. Risk mitigation is top of mind as well for insurance companies, and can likewise be addressed by analytics tools.

“Insurance is about providing better risk management solutions to our customer while effectively managing the company exposure management, comprising a mixture of appropriate products/services and risk mitigation strategies,” said Balu. “From identifying the root of a problem (diagnostic analytics) to anticipating the problem (predictive analytics) to identifying solutions (prescriptive analytics), analytics tools are ultimately helping insurers make better, faster decisions. For example, if you can predict a risk on a product being offered to a customer, then you can prescribe the solutions to mitigate that risk. This allows for risk prediction and price optimization.”

In his new role at AXIS, Balu is initially focusing on using analytics to better understand clients’ needs, which will help the company provide more tailored products and services.

“We view data and analytics as helping us put better tools and information in the hands of our people – which ultimately bring our clients more value from quote to policy to claims,” he said.

Looking ahead, the future of data and analytics in insurance is bright, with Balu predicting that the industry will continue to embrace digital innovations and new technologies in underwriting as well as in business interactions with customers.

“I see the industry continuing to build out algorithms to enhance underwriting operations and risk assessments. I also see the industry increasing the use of natural language processing (NLP) when quoting clients. Finally, I see data becoming more democratized in that our people will have better data at their fingertips, which will help them make better decisions and ultimately bring more value to their clients,” said Balu.

Original Post


General Timeline
Multiple class action and direct lawsuits in a variety of jurisdiction are filed against Axa, Trans, Lincoln, and others for breach of contract and false advertising relating to their COI Increases.
Risk Timeline
Industry gains in liquidity driving yields to mid-teens. Although volume in the secondary market is still sub $2b the tertiary industry continues to trade over $7-10b/ year of its available $90b of owned policies.