1 Making Health Care More Affordable: A Bipartisan Reform Agenda Around Chronic Disease Prevention and Management Kenneth E. Thorpe Emory University and.

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Making Health Care More Affordable: Making Health Care More Affordable: A Bipartisan Reform Agenda Around A Bipartisan Reform Agenda Around

Chronic Disease Prevention and Chronic Disease Prevention and ManagementManagement

Kenneth E. ThorpeKenneth E. ThorpeEmory University andEmory University and

Executive Director, Partnership to Fight Chronic DiseaseExecutive Director, Partnership to Fight Chronic [email protected]@sph.emory.edu

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Health Care Reform Debate in Health Care Reform Debate in

20092009 Largely unsuccessful in enacting reforms Largely unsuccessful in enacting reforms

nationally for the past 60 yearsnationally for the past 60 years Many lessons from our last national effort Many lessons from our last national effort

in 1993-94in 1993-94

THIS TIME WE NEED ATHIS TIME WE NEED A:: New messageNew message New strategyNew strategy A bipartisan approachA bipartisan approach

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System ReformsSystem Reforms

Need to make health insurance more Need to make health insurance more affordable for the 250 million affordable for the 250 million Americans with health insuranceAmericans with health insurance

96% of those who voted in 2006 had 96% of those who voted in 2006 had health insurancehealth insurance

Their number one concern and Their number one concern and anxiety was over the cost of health anxiety was over the cost of health care and whether their employer (or care and whether their employer (or the state) was going to continue to the state) was going to continue to provide coverageprovide coverage

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Six Unhealthy Six Unhealthy Truths Tell Truths Tell the Story of the Story of the Rise of the Rise of

Chronic Chronic Disease and Disease and Its Impact on Its Impact on Health and Health and Health Care Health Care in the U.Sin the U.S..

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133 million Americans, representing 45% of the total population, have at least one chronic disease

Chronic diseases kill more than 1.7 million Americans per year, and are responsible for 7 of

10 deaths in the U.S.

Truth #1Truth #1: Chronic diseases are : Chronic diseases are the #1 cause of death and the #1 cause of death and

disability in the U.Sdisability in the U.S..

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During 2007, the U.S. spent over $2.2 trillion on health care

Truth #2Truth #2: Patients with chronic : Patients with chronic diseases account for 75% of the diseases account for 75% of the nation’s health care spendingnation’s health care spending

In public programs, treatment of chronic diseases constitute an even higher

portion of spending:More than 96 cents in

Medicare……and 83 cents in

Medicaid

Of every dollar spent…

…75 cents went towards treating patients with one or more chronic

diseases

“The United States cannot effectively address escalating health care costs without addressing

the problem of chronic diseases.”

-- Centers for Disease Control and Prevention

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Truth #3Truth #3: Two-thirds of the increase in : Two-thirds of the increase in health care spending is due to increased health care spending is due to increased prevalence of treated (primarily) chronic prevalence of treated (primarily) chronic

diseasedisease

$0

$100

$200

$300

$400

$500

$600

$700

'87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00

~$211 billion

Level 0f health spending among thenoninstitutionalized U.S. population, 1987–2000

$313.5

$627.9= Increase attributable to rise in prevalence of treated chronic disease

(in billions of nominal dollars)

Years

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% of Adult Population Treated, By % of Adult Population Treated, By Medical Condition, 1987-2005: Rapid Medical Condition, 1987-2005: Rapid

Rise in Disease PrevalenceRise in Disease Prevalence Medical ConditionMedical Condition 1987 % 1987 % 2005 %2005 %

Mental DisordersMental Disorders

HyperlipidemiaHyperlipidemia

HypertensionHypertension

DiabetesDiabetes

Pulmonary Conditions (OPD, Pulmonary Conditions (OPD, Asthma)Asthma)

Lupus/Other RelatedLupus/Other Related

ArthritisArthritis

Back ProblemsBack Problems

Upper GIUpper GI

Heart DiseaseHeart Disease

5.5%5.5%

1.5%1.5%

13.6%13.6%

4.0%4.0%

9.5%9.5%

4.854.85

7.8%7.8%

5.4%5.4%

3.8%3.8%

8.1%8.1%

18.8%18.8%

14.4%14.4%

22.0%22.0%

8.0%8.0%

18.4%18.4%

6.0%6.0%

13.6%13.6%

13.2%13.2%

10.7%10.7%

9.5%9.5%

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Why Does Treated Prevalence Why Does Treated Prevalence Rise Over Time?Rise Over Time?

Rise in the incidence of diseaseRise in the incidence of disease Technology (treatment expansion)Technology (treatment expansion) Changes in clinical thresholds (metabolic Changes in clinical thresholds (metabolic

syndrome) for treating asymptomatic syndrome) for treating asymptomatic patientspatients

Better disease detection and screening Better disease detection and screening (both by patients and physicians—(both by patients and physicians—depression)depression)

LongevityLongevity Others? Others?

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Truth #4Truth #4: The doubling of obesity : The doubling of obesity between 1987 and today accounts for 20 between 1987 and today accounts for 20

to 30% of the rise in health care to 30% of the rise in health care spendingspending

No data <10% 10%-14%

Percent of U.S. Adults Who are Obese*198

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*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person

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No data <10% 10%-14% 15%-19% 20%-24% 25%-29% >30%

*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person

Truth #4Truth #4: The doubling of obesity : The doubling of obesity between 1987 and today accounts for 15 between 1987 and today accounts for 15

to 30% of the rise in health care to 30% of the rise in health care spendingspending

If the prevalen

ce of obesity was the

same today as

1987, health care

spending in the US would be nearly 10 percent

lower per person—

about $200

billion less

The percent

of children

and youth

who are overweig

ht has tripled since 1980

Percent of U.S. Adults Who are Obese*200

5

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1.57 1.28

1.5 2.5

1.05

2.260.56

1.42

0.4

1.37

0

2

4

6

8

10

1976-1980 1999-2004

Year

Diabetes Prevalence among U.S. Adults Aged 20 - 74

BMI CategoryBMI Category

Obese III (Obese III (>> 40) 40)

Obese II (35-40)Obese II (35-40)

Obese I (30 -35)Obese I (30 -35)

Overweight (25 -Overweight (25 -30)30)

Normal / Normal / underweight underweight

(<25)(<25)

TotalTotal

5.03%

8.83%

Age and sex adjusted (from Gregg, 2005)

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The Centers for Disease Control and The Centers for Disease Control and Prevention (CDC) estimates…Prevention (CDC) estimates…

80% of heart disease and 80% of heart disease and strokestroke

80% of type 2 diabetes80% of type 2 diabetes 40% of cancer40% of cancer

… …could be prevented if only could be prevented if only Americans were to do three things:Americans were to do three things:

Stop smokingStop smoking Start eating healthyStart eating healthy Get in shapeGet in shape

Management of chronic disease Management of chronic disease could also be significantly improved: could also be significantly improved: Chronically ill patients receive Chronically ill patients receive only only 56%56% of the clinically recommended of the clinically recommended preventive health care servicespreventive health care services

Truth #5Truth #5: The vast majority of cases of : The vast majority of cases of chronic disease could be better chronic disease could be better

prevented or managedprevented or managed

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National survey conducted in April 2007 on Americans’ views of chronic disease and its impact

on health and spending

Truth #6Truth #6: Many Americans are unaware of the : Many Americans are unaware of the extent to which chronic disease harms their extent to which chronic disease harms their

health – and their walletshealth – and their wallets

Percent of Americans who believe Percent of Americans who believe chronic disease is responsible for the chronic disease is responsible for the following percent of death and health following percent of death and health

spending in the U.S.spending in the U.S.

Percent answering:Percent answering: DeathDeathSpendiSpendi

ngng

Less than 10%Less than 10% 33 66

10% but less than 10% but less than 20%20% 88 88

20% but less than 20% but less than 30%30% 1414 1212

30% but less than 30% but less than 40%40% 1515 1010

40% but less than 40% but less than 50%50% 1515 1212

50% but less than 50% but less than 60%60% 1212 1111

60% but less than 60% but less than 70%70% 77 99

70% but less than 70% but less than 80%80% 88 77

80% but less than 80% but less than 90%90% 44 33

90% to 100%90% to 100% 33 44

Not sureNot sure 1010 1818

Only a small fraction of Americans, less than one in six, comprehend the magnitude of the problem:

That chronic diseases represent more than 70% of the deaths in the U.S. and more than 70% of health care costs

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Slowing the Growth in Healthcare Slowing the Growth in Healthcare Spending and Managing the Level Spending and Managing the Level

of Spendingof Spending

Need to broaden the debate to focus on rising Need to broaden the debate to focus on rising population disease prevalencepopulation disease prevalence. Current focus on . Current focus on high deductible plans not likely to affect these high deductible plans not likely to affect these trends, and could make matters worse for trends, and could make matters worse for chronically ill patients.chronically ill patients.

Need to better manage care provided to the Need to better manage care provided to the chronically ill—chronically ill—they acct for 75% of the spend, they acct for 75% of the spend, receive less than optimal care. This will require us to receive less than optimal care. This will require us to change how we pay for services. It will also require change how we pay for services. It will also require us to modernize our health care IT and delivery us to modernize our health care IT and delivery systems—this will not happen absent major changes systems—this will not happen absent major changes in how payers like Medicare pay providers to treat in how payers like Medicare pay providers to treat the chronically ill.the chronically ill.

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Common sense approaches for Common sense approaches for slowing the growth in spendingslowing the growth in spending

1.1. Key Issues: Slow rise in treated disease Key Issues: Slow rise in treated disease prevalenceprevalence through, through,

• Slowing the rise in obesity prevalence among children and Slowing the rise in obesity prevalence among children and adults.adults.

• Need to broaden discussion of reform to include primary Need to broaden discussion of reform to include primary care, primary prevention. Should be a center piece of any care, primary prevention. Should be a center piece of any cost containment effort. cost containment effort.

2.2. Policy ToolsPolicy Tools• School Based Interventions (both calories and School Based Interventions (both calories and

intervention)intervention)• New and effective health promotion, wellness, disease New and effective health promotion, wellness, disease

prevention programs available for all adults – perhaps a prevention programs available for all adults – perhaps a universal wellness and health promotion benefit for alluniversal wellness and health promotion benefit for all

• Financial incentives to participateFinancial incentives to participate

3.3. Modernize our health care delivery Modernize our health care delivery systemsystem. .

• Need modern IT infrastructure and integrated delivery Need modern IT infrastructure and integrated delivery models to address both the clinical and cost issues to care models to address both the clinical and cost issues to care for the chronically illfor the chronically ill

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SummarySummary

Changes outlined above requires Changes outlined above requires fundamental restructuring of the US health fundamental restructuring of the US health care delivery systemcare delivery system

Attacking key drivers of rising spending Attacking key drivers of rising spending which require a broader set of policy which require a broader set of policy options.options.

Need to focus on improving the care for Need to focus on improving the care for chronically ill patientschronically ill patients

Develop national strategy for addressing Develop national strategy for addressing rise in treated disease prevalencerise in treated disease prevalence

Devote resources to developing effective Devote resources to developing effective health promotion, wellness programs for health promotion, wellness programs for use in schools, and the worksite.use in schools, and the worksite.