About psychiatry and the insurance industry’s impact on financial support systems for ME patients, in Denmark and Norway.
Insurance companies that have financial advantage of having ME defined as a psychosomatic disorder connect with health professionals and researchers with exactly this understanding of the disease. In addition, these companies fund research that can be used as an argument to reject claims for compensation. Here, a Nordic network with links to the insurance industry is revealed.
The Danish Labour Market Insurance, (the national system for occupational injuries and occupational diseases) rarely covers injuries and illnesses of a psychosomatic nature. According to the newspaper Information, psychosomatic illness is covered by only 7 %, against somatic illness by 77 %.
Most Danes have private health insurance. Danish lawyers now warn of insurance companies often insisting on using specialists with a history of issuing medical evaluations in favor of the insurance companies. In some cases, they write medical statements in which symptoms are described as being psychosomatic or non-existent. In evaluating insurance claims, this can be interpreted as «pain in life» – that the illness is not real, and thus the application for compensation is rejected.
Compensation and disability benefits are not granted before the health situation has been clarified, and as long as there are treatment options – the situation is not considered as clarified. With a psychosomatic diagnosis, it can be very difficult to get compensation.
The Danish psychiatrist Per Fink is head of Aarhus University Hospital, the Research Unit for Functional Disorders and Psychosomatics. Fink received a lot of attention in the media when he forcibly admitted a young ME-patient, Karina Hansen, to a psychiatric hospital for several years – against her and her parents’ will.
Facsimile from Dagens Medicin 9. mai 2015
Functional disorders are the same as psychosomatic, somatoform disorders (health anxiety) and «hysteria» which are assumed to have their cause in emotional (psychological) conditions. Per Fink and his unit issue psychosomatic diagnoses, and Fink is known for his many years of efforts to re-classify the disease Myalgic Encephalomyelitis (ME) to a functional disorder. This is contrary to the World Health Organization, WHO, which has classified ME as a neurological disease since 1969. Health authorities in both the US and the UK have concluded that ME is a physiological disease and do not recommend therapy as a cure.
Also read “Why functional medicine is bogus” by Dr. Harriet Hall.
TrygFonden and funding of research
In 2012, Bente Stenfalk estimated that the Danish insurance company TrygFonden had donated more than 100 million Danish kroner to Fink’s unit at Aarhus University Hospital; for research, courses and conferences, books and brochures and distribution of these, as well as education of doctors in functional disorders. This helps to maintain the perception that ME is a functional disorder, both among health professionals, authorities, politicians, and the general population. With the research they fund – which ignores the results of new, international biomedical research – they can save large sums in insurance payments.
From TrygFonden’s strategy document in 2009:
«Functional disorders are a considerable part of the long-term sick leave and early retirement. There is a strong – and partly documented – suspicion that the health service, social authorities and possibly also the possibility of obtaining compensation significantly increase the morbidity of people with functional disorders.»
In 2014, TrygFonden conducted a large population survey about people’s attitudes towards functional disorders. More than 4,000 people were interviewed, and the cost is estimated at 10 million danish kroner. One specific purpose of the survey was to influence people’s attitudes about which disorders can be perceived as functional.
This quote from TrygFonden’s strategy-document to the survey reveals how one seeks to categorize e.g. ME patients:
«Or should the ‘functional’, for example, be seen as discouraged people with ‘pain in life’, trying to avoid the demands of the labor market (and the world)? In that case, these disorders may be seen as «the unjust lot of life» rather than as problems that society should and can solve. A third possibility is to see them as work-shy people who don’t want to contribute to society. «
The questions are designed with a framing effect, context bias. Such questions are made with a choice of words that evoke a particular understanding or emotion, and which thus influence the answers in a desired direction. The framing effect can be achieved by having specific information and statements in the question, and thus influencing the answer. Here is an example from the survey:
Q. 29 How much do you agree or disagree with the following views.
1. It is too easy today to receive disability pension and similar benefits
2. It is too easy to avoid problems at work or in the family by calling in sick
3. Illness is often used as an easy way out of the labor market by people who don’t think they are able to meet the demands of the labor market.
Scale: Totally disagree, Disagree, Neither agree or disagree, Agree, Completely agree, Don’t know.
Chronic fatigue syndrome is mentioned in 10 of 25 questions. Thus, the idea that the disease is a functional disorder is upheld amongst the population. The questionnaire is designed with contributions from e.g. Per Fink and his colleague at Aarhus University Hospital, chief physician Lene Toscano.
On 10 July 2020, the Danish Society for Functional Disorders (DASEFU) was established. Lene Toscano is a board member. TrygFonden recently allocated DKK 3 million for education in functional disorders. The education program will be developed in collaboration with DASEFU. DASEFU has been admitted as a member of The organization of Danish Medical Societies. This way, they automatically receive new publications from the National Board of Health for consultation, ie have the right to provide input and influence decisions on treatment methods in the health care system.
Per Fink and TrygFonden
In 2011, Per Fink’s unit received DKK 10 million Danish kroner from TrygFonden to research “unexplained pain”. This resulted in the report “Prevalence of functional somatic syndromes and bodily distress syndrome in the Danish population: the DanFunD study in 2020.
Per Fink’s latest article; “Assessment of functional somatic disorders in epidemiological research: Self-report questionnaires versus diagnostic interviews”, was funded by two insurance companies:
More donations from TrygFonden
TrygFonden has also funded chief physician Lone Overby Fjorback’s research: «Mindfulness therapy for somatization disorder and functional somatic syndromes – Randomized trial with one-year follow-up» 2012. The study is presented as if the result was positive, even if though it was negative: » The physical functioning subscale of the SF-36, which measures impairments in physical activities such as climbing stairs, changed very little in the mindfulness therapy group. The study is part of Fjorback’s doctoral dissertation which was supervised by Per Fink.
Fjorback is now head of the Danish center for Mindfulness at the Department of Clinical Medicine at Aarhus University – which is funded by TrygFonden. She is also manager of the entity of functional disorders at Lillebælt hospital. On March 13, 2021, the Danish journal Videnskab (Science) writes that Fjorback offers free courses in mindfulness. Videnskab is funded by i.a. TrygFonden.
In 2013, physician Anna Budtz-Lilly at Aarhus University received almost 1 million Danish kroner from TrygFonden in 2013 to research functional symptoms https://dagensmedicin.dk/anna-budtz-lilly/. In the same year, Lene Toscano received DKK 3.3 million from TrygFonden to investigate how best to disseminate and share knowledge about functional disorders.
Per Fink was part of the editorial committee that prepared the brochure «When the body says no«. It is distributed at many Danish employment offices and is financed by TrygFonden.
These publications do not use recognized diagnostic criteria for CFS/ME. In other words, they are not even relevant for ME-patients but are still used by e.g. insurance companies to recommend therapy as treatment to get ME patients back to work.
Compensation and pension systems for illness and injuries are not given as long as there are treatment alternatives. One of the largest studies on treatment for ME is the scandalous PACE-trial. This study concludes (incorrectly) that graded exercise therapy has a positive effect on ME. This is useful for insurance companies that can use the study to argue that ME patients can be cured by exercising and can return to work.
The insurance company Swiss Re wrote in a newsletter in 2013 about a web-meeting with one of the authors of the PACE-trial, psychiatrist Peter White. The topic was: What can insurance companies do to get claimants with chronic fatigue syndrome healthy and back to work? White, and three other authors of the PACE study have done paid consultancy work for Swiss Re and/or other insurance companies. See Conflicts of interest.
Another author of the PACE-trial, psychiatrist Michael Sharpe, recently gave a presentation to Swiss Re on Long-Covid. Sharpe suggests that one of the causes of Long-covid is «social factors.»
Swiss Re also has offices in Denmark, and on their website Per Fink is presented as «Head of Research and Chief Physician». In 2017, Fink gave a lecture at Swiss Re’s medical conference. He spoke about a severely ill 26-year-old patient with the diagnoses fibromyalgia and chronic fatigue syndrome. In the discharge letter, he changed the diagnosis to «somatization disorder».
Per Fink and the Danish health authorities
Fink was also represented in the committee that prepared the Danish health authorities’ guidelines for «Functional disorders, Recommendations for assessment, treatment, rehabilitation and destigmatization» published in 2018. The guidelines include chronic fatigue syndrome/myalgic encephalomyelitis, CFS/ME.
The guidelines refer i.a. to another controversial and partially withdrawn systematic review by Lillebeth Larun, researcher at the Norwegian National Institute of Public Health: Larun L., et. al. Exercise therapy for chronic fatigue syndrome, 2017.
The Danish ME Association
The chair of the board of the Danish ME association, Cathrine Schultz Engsig, says it is difficult for ME patients to receive pensions and compensation from private insurance companies despite disability benefits and doctor’s statements confirming the ME diagnosis. The insurance companies rely on the National Board of Health’s interpretation of ME as a functional disorder and thus psychosomatic, which is often more difficult to obtain compensation for. This makes patients worse off because the insurance companies’ medical consultants can thus interpret the disease differently than the WHO; as a 100% physical illness with the diagnostic code 8E49.
TrygFonden and Per Fink in Norway
In 2019, the Danish National Board of Health ensured that physician Henrik Vogt, head of the Norwegian organization Recovery Norway, was invited to TrygFonden’s annual conference on functional disorders in Copenhagen where they also gave a lecture.
Recovery Norway (RN) was established in connection with the Norwegian Consumer Agency’s tightening the regulations for marketing alternative treatment. The restriction lead to that alternative practitioners are no longer allowed to use customers’ positive experiences in marketing. RN mainly conveys stories of personal, positive experiences with the alternative method Lightning Process (LP). The organization was started by i.a. a number of LP instructors and their family members. They have a financial interest in the organization’s lobbying and marketing. LP is mainly marketed towards ME. RN consistently refers to ME as psychosomatic or MUPS: medically unexplained physical symptoms.
On 14 May 2019, several representatives from the Danish Health and Medicines Authority visited Recovery Norway. The meeting was held at the University of Oslo. Present at the meeting were i.a. press manager at Aarhus University Hospital Lars Elgård Pedersen who works closely with Per Fink and Lene Toscano. Lillebeth Larun from the Norwegian National Institute of Public Health and pediatrician Bård Fossli Jensen from Catosenteret also participated.
Henrik Vogt, who is also employed at the Center for Medical Ethics at the University of Oslo invited the National Institute of Public Health to the meeting, on the grounds that it would be positive, and that he knows someone «who is on the same page»:
The situation in Norway
The alternative method LP is also marketed to insurance companies in Norway. LP-instructor Live Landmark has given a lecture for Tryg Forsikring in Norway.
Recovery Norway has given lectures for the Norwegian Medical Association, the National Competence Unit for CFS/ME, the Ministry of Health and Care Services, the Norwegian Directorate of Health, and has invited themselves to join the Norwegian Directorate of Health’s expert group to develop procedures for how to care for fatigue-related conditions. Recovery Norway is listed as a patient organization on the National Competence Unit for CFS/ME’s websites.
Recovery Norway will contribute with user participation in a planned Norwegian study where 100 ME-patients will be treated with Lightning Process. Ph.D.-candidate is LP-instructor Live Landmark. The study is funded by the Research Council of Norway, approved by the Regional Committees for Medical Research Ethics, and is supported by the Norwegian Directorate of Health, and the National Institute of Public Health. The Norwegian Labour and Welfare Administration (NAV) will be recruiting participants. Participants who deteriorate due to the treatment can be referred to a district psychiatric center, DPS.
The study is designed for a positive result. Read more about the study design here: Study on ME patients; Cynical, unethical and indefensible.
If the study is completed, the following report may give NAV the opportunity to demand that ME-patients take courses in LP to meet the requirement for appropriate treatment in order to receive financial support. It is known that ME patients spend up to 7 years on work clarification allowance, AAP, pending the illness to be clarified – before disability benefits can be assessed.
Read more about the study in Adresseavisen, by prof. Ola D. Saugstad and Nina E. Steinkopf: The ME controversy: Study on Lightning Process at NTNU.
In May 2020, Dagbladet had an article across 11 whole pages about the «ME-war«. Per Fink and Henrik Vogt were interviewed and it is claimed that ME researchers and professionals are harassed and threatened to silence. On March 17, 2021, principal of the University of Oslo, Svein Stølen, picked up on this. He has taken the initiative to establish a commission to look into the matter. Today, 22nd April 2021, Stølen attended a meeting with the Freedom of Expression Commission.
Links between private companies and official bodies who have a strong financial interest in specific research results are not new, as the history of both the tobacco- and oil industries shows. The link between insurance companies and researchers with a particular understanding of ME is not only an attack on free research, but also an attack on seriously ill people who don’t receive legitimate insurance- and social security benefits.
Written by Nina E. Steinkopf
Former HSEQ Chief Executive
Now: ME-patient and writer
This article was updated 24th and 26th April 2021.