A few weeks ago, I had a physical exam for the life insurance policy I recently purchased. It was yet another somewhat routine, seemingly insignificant event that brought myriad revelations about myself—and also the world of health care. I was going to publish these reflections right away, but for whatever reason, I thought it was best to make sure all the paperwork went through before I went ahead and wrote about them. (I wonder if there are any actuarial data out available regarding the risks of being transparent and “putting oneself out there” in the world…)
I have to be honest. I was nervous about going through the process of getting life insurance, for many reasons. Number one, there was a lot at stake. I am determined to ensure that my family is taken care of when I am no longer on this planet. Some people may not want to cross that road in their consciousness, but I don’t mind it at all. I’d rather be prepared. I applaud my late father for living by example in this regard. He wasn’t obsessed with death, but he dealt with its inevitability head-on and made sure his “affairs were in order” long before any order seemed necessary. Although I am years behind where my dad was at my age in the preparation-for-death arena (I should have gotten a new life insurance policy a decade ago), I am trying to emulate him as best I can in this regard.
Number two, I tend to have an irrational fear that I will be disqualified from things. When I was eight, I was in a swim contest, and the boy in the lane next to me was deemed ineligible to participate after he prematurely dove into the water two consecutive times. Maybe it was witnessing this misfortune that caused me always to reflect on how easily one can be cast aside for misunderstandings, missteps and—gasp!—mistakes. In actuality, my record of disqualifications is minimal. (I haven’t won many medals for things, but I haven’t been disqualified from any type of competition, either. I was kicked out of jury duty once, but was because the lawsuit tangentially involved one of my former clients.)
Number three, I knew I had to have a physical exam and some labs drawn in order for my application to get through underwriting, and just like in high school, there are some subjects I test better in than others. Over the past several years, for example, my blood pressure has been creeping up ever so incrementally into that “prehypertension” level of 120/80 mmHg. While I wanted to be a grown-up and place the blame for these readings squarely on my shoulders, I couldn’t help but secretly curse the blood pressure classification system that had been imposed on patients by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC). I was not aware of the power of this committee until I began writing about blood pressure management in the 90s. Almost immediately, I learned how significantly patients’ and clinicians’ perceptions of hypertension have changed with the JNC at the helm. Since the 1970s, the committee has issued seven reports updating physicians on the best way to detect, diagnose, and treat hypertension. With every update penned, the definitions have become more stringent. Back in 1977, when it published its first report, the JNC classified high blood pressure as 160/95 mmHg, but the group advised physicians to recheck the measurements within one month before prescribing treatment. (If the bottom number—the diastolic blood pressure—was 120 mmHg or higher, patients were to be “promptly referred” to medical care.) With the publication of its 6th report in 1998, the committee began categorizing two consecutive, same-day readings of 140/90 mmHg as “Stage 1” hypertension. In its 7th report, published in 2003, the committee introduced a new stage, “prehypertension,” which ranged from 120/80 to 139/89 mmHg, and declared that most patients with a BP of 140/90 mmHg would require a “thiazide-type diuretic”—not just a better diet and improved exercise—to ameliorate their condition. This decade-old guideline is still in use today (although the 8th JNC report is expected to be out soon).
My just-enough-to-be-dangerous knowledge about the history of hypertension’s diagnostic parameters was doing me no good. In fact, every time I thought about my chances of reaching the dreaded 120/80, I felt the blood pump more fiercely within my vessels. A few days before the scheduled exam appointment, I decided to do only what I had in my power to do: stay hydrated (I read that dehydration could cause high blood pressure), reduce my sodium, eliminate caffeine, and clean my house (since the life insurance company had recommended the exam be done comfort of the policy holder’s home.) I took long, peaceful walks along the lake near my house. When at last the Monday morning appointment arrived, I made sure the dining room table was wiped clean, then I sat with my annotated Sherlock Holmes anthology and a glass of water until the doorbell rang.
The whole appointment lasted 15 minutes. Far from nerve-wracking, the experience was fascinating. The nurse was friendly and considerate. After breezing through the usual screening questions (“Have you ever fainted when your blood was drawn? When did you last have something to eat or drink other than water?”), she pulled the blood pressure cuff and sphygmomanometer from her bag. Unaware of my apprehension, she wrapped the cuff around my arm and began pumping. I braced for the worst.
“110/70,” she said. “Which is good. We require two measurements so I’ll do this once more.”
More pumping. More deflating. More listening.
“108/69,” she declared.
I think she could see the surprise that registered on my face. “What were you expecting?” she asked as she jotted down the numbers.
I tried to act casual. “Well, since my daughter was born, every time I’ve been to the doctor, it’s been reading a little high—122, 125,” I said. “And whenever they do the repeat measurement, it always reads higher.” (I didn’t disclose that the diastolic reading of 108 was the lowest I had seen in years.)
“Hmmm,” reflected the nurse. She stopped writing on the application form and looked up. “I bet your daughter was born around 2000?”
“I’m guessing they have been using the automatic inflating blood pressure machines.”
“That makes sense. Clinics seemed to have started using those auto-inflating cuffs more widely right around 2000,” she explained. “We used to use them for our in-home exams, too, but we stopped some years ago when we were seeing unusually high numbers. Sometimes they can register inaccurate readings—both low and high. The mercury sphygmomanometer is still the preferred method.”
True to my journalist self, I made a mental note to check her assertions. I didn’t want to be falsely hopeful, but I did find it comforting to know that my blood pressure wasn’t high with the manual device.
After she completed the EKG, took a blood sample, and packaged up my urine specimen, it was time for her to get to the next appointment. I thanked her (perhaps more profusely than if my testing had not yielded some positive results) and held the door open for her as she schlepped her equipment bag and paperwork to her car.
When she left, I did a search on the topic. I found a letter published in a 2001 issue of the British Medical Journal that anecdotally reported falsely high readings with automatic blood pressure devices. Reading on to a National Health Statistics report published in late 2012, I learned that mercury sphygmomanometers remain the “gold standard” for measuring blood pressure and that inadequate validation through calibration and other means can affect the accuracy of the electronic blood pressure devices. Had I not had this somewhat-chance encounter with a nurse during a life insurance exam, I might never have known that the accuracy of automatic blood pressure devices was ever even in question.
I was in a cheerful mood the whole rest of the day. I’m not sure why. I think it was just empowering to know that I had taken one more step to provide for my family, and I was definitely relieved that the whole testing process was over and that it had gone well.
Two weeks later, the results of my exam processed, the underwriters approved my policy. In the end, it didn’t matter that I was at a “healthy” weight, that I had good blood pressure, a normal complete blood count (CBC) panel and no hyperglycemia. It didn’t matter how much water I had consumed that morning or how long I had avoided chocolate and sodium-rich foods. During a respectful email exchange, my insurance agent informed me that due to my mother dying before age 60 (of cancer), I had been bumped to a higher-risk category and would have to pay $20 more than estimated if I wanted maintain the same level of coverage I had originally requested. I was not surprised. He had shared the underwriting guidelines with me when I filled out my application. We discussed the rate scenarios should I be reassigned to a different risk category. The cards of my family’s medical history were stacked against me. I knew all of this, but for some reason, I held fast to the notion that my own personal health could change the outcome.
I decided to pay the extra 20 dollars per month to keep the same level of coverage. Although I don’t entirely comprehend the actuarial circumstances that cast me into the highest premium rate for a non-nicotine user, in this case, I don’t mind bowing to the system. I am happy. I have something I have wanted for a long time: a little peace of mind. I have some reassurance that those who will outlive me will be okay financially for a while when I die. I am a life insurance policyholder.
And a fairly healthy one at that.