The emotional debate that surrounds genetic tests, which reveal predisposition to disease, is masking the numerous opportunities that the genetic revolution can unearth for patients and insurers, says Dr Achim Regenauer

The future lies in the genes." Discoverer of the structure of our inherited material, DNA, James Watson recognised the significance of genetics almost 50 years ago. The general public associates the decoding of the human genome with `Big Brother' scrutiny. For many, this idea is associated more with concerns that in the future, thanks to the new possibilities opened up by gene tests, insurance companies could exclude people with disadvantageous risk profiles from being insured. Consequently, the public debate is concentrating on predictive gene tests, i.e. those tests that establish with certain probability a predisposition to a particular disease. Here, it is often overlooked that to date such tests are only available for rare inherited diseases. In this emotional debate, however, the numerous opportunities of the genetic revolution that will unfold not only for patients but also for insurance clients are often ignored.

The future of the genes prophesied by James Watson is currently being realised in the area of clinical research with new and promising applications that will also clearly influence the insurance industry. Over the next ten years it is likely that more pharmaceutical drugs will be approved with quite different targets that specifically make use of the newly gained knowledge from gene research (genomics). The first concrete example can be found in the cancer drug Gleevic which in clinical studies has shown very encouraging results with a particular kind of leukemia. Thus, it no longer seems utopian to think that in the future some currently incurable forms of cancer might be transformed to a chronic form or even completely cured.

Another practical application area for gene research are the so-called pharmacogenetic tests that enable individually tailored drug therapies to be administered according to the genetic predisposition of each patient. Pharmaceutical firms have already promised that the first drugs where a pharmacogenetic test is carried out before taking the medication will appear within the next few years. In this instance, optimism is justifiable, not just with reference to clear reductions in adverse drug effects, but also for better drug responses. Until now both components have greatly needed improvement in clinical medicine. In the US alone, around 100,000 patients die annually from the side effects of pharmaceuticals. On the other hand, up to 50% of high blood pressure patients receive insufficient or sometimes no treatment at all, either because the prescribed drug has no effect or it is not reliably taken by the patient due to side effects.

Predisposition
Until now, clinical medicine could often only take on a therapeutic role when the first symptoms of a disease appeared. Gene tests, however, can recognise the predisposition to an illness years before it becomes manifest - if not with absolute certainty, at least with a certain degree of probability. In the future, genetic diagnostics offers the possibility of taking effective preventive measures with many diseases: the affected person can counteract the disposition through altering their life, style and/or the doctor can delay or prevent the onset of a disease by prescribing the appropriate pharmaceuticals.

In addition, new genetics will provide decisive insights into disease processes at the cellular and molecular level. In the middle of the 19th century, the introduction of the light microscope revolutionised medical thinking and research such as the discovery of microorganisms, investigation of cells, and discrimination between benign and malign tissues. Genetic research as unparalleled medical revolution will supersede all previous standards. To a considerably greater extent it will change the medical thinking of the 21st century. Molecular-oriented medicine opens up completely new dimensions of diagnostic and therapeutic possibilities - medicine will be `geneticised'.

These three examples show the wide-ranging innovation spectrum that gene technology covers in the health sector alone. For reasons of space, other possibilities such as gene therapy and stem cell research cannot be described here. It goes without saying, however, that all these developments will also have a lasting influence on the insurance industry.

Morbidity assessment
Contrary to a frequently expressed idea, in the future gene tests will not allow a personal glimpse into the crystal ball of fate with an exact calculation of our life expectancy. However, it is possible that in the future gene tests for widespread disorders such as diabetes, strokes and cancer can reduce the degree of uncertainty about subsequent disease events. Should national legislation then prohibit taking gene tests into account in underwriting, this will have clear, negative consequences in the medium-term for life and health insurances.

Already, it is becoming apparent that diseases such as high blood pressure, coronary heart disease, cancer or diabetes mellitus, until now primarily defined clinically, can be subdivided into individual smaller disease groups requiring different therapy strategies using genetic diagnostics. It is self-explanatory that these sub-groups show various prognostic courses. These must increasingly be taken into consideration, in accordance with legislative and political positions, in not only underwriting for health but also for life insurance. In contrast to the widely expressed fear that many customers in the future will no longer be insurable, Munich Re expects a significant increase in insurability: patients with impairments, who could not until now be offered insurance coverage, would profit from this development, as was already made possible by the non-genetic medical progress of the last few decades.

Paradigm change to preventive medicine
Genetics will provide new insights into the causes of diseases and reveal which targets to hit, how the outbreak of disease can be delayed, or possibly even prevented. Perhaps even the concept of disease itself will change. Already, geneticists assume that every individual shows dozens of disease-causing flaws in their genetic make-up. It seems realistic that those gene tests that allow the patients to positively influence their given disease predispositions through changes of behaviour and/or drug treatments will infiltrate into the health system and society at large in the foreseeable future.

The potential here is immense. Take diabetes as an example. The initial diagnosis of this impairment is very often first established several years after the onset, at a point where irreversible changes in the blood vessels are already manifest and the chances of preventing heart attacks and strokes are already reduced. Here, the health insurer in particular must adapt to quite new demands; how should the growing need for preventive check-ups and the associated required treatment options be accommodated?

Cost developments in the health system
Medical progress, the ageing population and increasing health awareness are already leading to exploding costs in the health system. Genetic research will, if anything, emphasise these aspects particularly through increasing life expectancy and the wish for improved quality of life, but neither is reached without extra costs. Moreover, the national health systems must now also reckon with the additional preventive measures presently being made possible through genetic research. So in many places, states' financing capabilities are reaching their limit, meaning one must reckon with a growing proportion of personal provision and the increasing use of private insurances, overtaking state provision. Since the individual health budget of the privately insured is also not unlimited, health insurers must increasingly consider how far they can contribute to new insurance concepts and innovative products, to efficiently use the emerging prevention offerings. Why not reward those insureds, who through health-conscious behaviour create fewer subsequent costs, with a premium reduction?

The role of Munich Re
The rapidly accelerating development in this area has now prompted Munich Re to centralise specialists with expert knowledge in the various application areas of gene technology in a multi-disciplinary competence centre for life sciences in Munich.

Here, the advances in genetic research will be continuously monitored and analysed for possible consequences for the insurance sector (life, health, casualty and property). The first result of these investigations will appear towards the end of this year in the form of a detailed status report that follows up the range of gene technology publications. In addition, this competence centre sees itself as a central contact partner for gene technology enquiries in the most diverse insurance areas. Together with our experts and - where necessary - external specialists, we seek joint dialogue with our business partners to work out innovative solutions for problem faced by ceding companies.

By Dr Achim Regenauer

Dr Achim Regenauer is chief medical officer of Munich Re and head of the competence centre for life sciences.

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