Rising Rates of Chronic Health Conditions: What Can Be Done?

Rising Rates of Chronic Health Conditions: What Can Be Done?

Conference Transcript
July 31, 2008

Welcome and Overview

Paul Ginsburg, president of the Center for Studying Health System Change, opened the conference by noting it was the first of four HSC conferences on major health policy topics sponsored by the Pharmaceutical Research and Manufacturers of America, the DMAA, the Care Continuum Alliance, and the American College of Preventive Medicine. Under the sponsorship arrangement, HSC and the three organizations jointly selected the topic, while HSC retained sole responsibility for organizing and conducting the conference. He noted that HSC would produce an issue brief summarizing the conference highlights and that future conferences would examine innovative approaches to chronic condition prevention and management as well as value-based health benefit structures.

Ginsburg observed that the escalating prevalence of chronic conditions has added significant cost to the American health care system. Prevention and more effective management of chronic illness are frequently cited as ways to improve health outcomes and slow the growth of U.S. health spending, or at least to extract better value from the $2.1 trillion spent annually on health care. He noted that in many respects, America's rising chronic disease burden reflects the remarkable advances in public health, workplace safety, and medical care over the past century. A hundred years ago, most people did not live long enough to develop a chronic condition -- in 1900, average life expectancy was 47 years; by 2008, it had reached 78 years. A century ago, the leading causes of death were infectious diseases like pneumonia, influenza, and tuberculosis, along with accidents and complications from childbirth.

Today, heart disease, cancer, and stroke top the list of leading death causes. While advances in medicine have been impressive, the health care system lags in providing early intervention and high-quality care for people living with chronic conditions. The system remains oriented toward acute episodes of care -- effective at treating a heart attack, but much less so at preventing and managing the underlying heart disease that leads to it.

Panel One: Chronic Conditions 101

Carolyn Clancy, M.D., Director of the Agency for Healthcare Research and Quality, underscored that rising chronic disease prevalence is, paradoxically, a byproduct of medical success in treating acute conditions. She described a health care system whose mindset remains dominated by acute care despite the chronic disease burden, noting that more people die annually from heart disease than from AIDS, tuberculosis, and malaria combined.

Clancy cited data from the Medical Expenditure Panel Survey showing that in 2005, approximately 60 percent of the U.S. adult population had at least one chronic condition, and three of every four dollars spent on prescriptions went toward treating chronic illness. Nearly four in ten adults between ages 18 and 34 had at least one chronic condition, as did nine out of every ten people aged 65 and over. She emphasized that for Medicare beneficiaries, chronic conditions represent the largest expenditure category yet receive the poorest quality of care.

She noted that approximately 85 percent of all health care spending goes toward caring for people with chronic conditions. According to the Milken Institute, 40.2 million cases of chronic disease could be prevented, yielding $1.1 trillion in savings by 2023 through reasonable improvements in prevention and management. Clancy acknowledged, however, that most of the scientific evidence base pertains to individual conditions -- deep knowledge exists for cardiovascular disease, diabetes, and some mental health conditions, but the evidence for managing patients with multiple co-occurring chronic illnesses remains thin, particularly when one of the conditions is a mental health disorder.

Clancy presented research showing that public reporting and transparency on quality had helped narrow black-white disparities for process measures -- the steps entirely under provider control in the exam room, such as ordering appropriate tests. But for outcome measures like actual control of hypertension, LDL cholesterol, and blood glucose in diabetes, disparities had not narrowed. She argued that achieving better outcomes would require stretching the boundaries of clinical care and creating new linkages between clinical delivery, community resources, and public health.

She highlighted AHRQ's work evaluating health IT applications for safety and quality improvement, annual reports to Congress on quality and disparities, and a collaborative initiative with area agencies on aging to address health disparities among Hispanic elders in eight communities. She also referenced an evaluation of patient self-management programs and emphasized that improving chronic disease outcomes is not solely a clinician challenge -- it is fundamentally about how patients live with and manage their conditions, driven more by motivation than by knowledge alone.

The Economics of Obesity

Eric Finkelstein, Ph.D., Health Economist and Director of the Public Health Economics Program at RTI International, framed obesity as fundamentally an economic phenomenon. He emphasized that rising obesity rates have affected all segments of the population, noting that higher-income groups -- not lower-income groups -- have actually experienced the fastest increases. Within specific racial and gender categories, particularly among men, socioeconomic status shows almost no gradient with obesity once race and gender are separated.

Finkelstein argued that broad economic forces drive obesity through three channels. First, the monetary and time costs of food acquisition have dropped -- food prices relative to other goods have fallen, and technologies such as microwave ovens, fast food, and pre-packaged meals have drastically reduced the effort needed to consume calories. The relative prices of fresh fruits and vegetables have risen compared to foods with added sugars and fats, which helps explain shifts in consumption patterns.

Second, physical activity has been squeezed out on both the leisure and occupational sides. Competing technologies -- the Internet, computer games, cable television -- crowd out leisure-time exercise, while nearly every occupation has been mechanized to the point where workers get almost no incidental physical activity. Finkelstein cited research showing that a lifelong sedentary occupation leads to roughly 25 additional pounds compared with a physically demanding occupation.

Third, he introduced the concept of "moral hazard" in obesity -- the idea that improved medical treatments for obesity-related conditions (such as statins for cholesterol management) have reduced the perceived health consequences of excess weight, potentially lessening the motivation to maintain a healthy weight. He cited CDC research showing that today's obese population has a better cardiovascular risk profile than normal-weight individuals did several decades ago, thanks to medical advances.

Finkelstein argued that these economic changes are not accidental but reflect consumer preferences for affordable products, labor-saving technology, and medical treatments that mitigate the consequences of poor health habits. He suggested that while obesity is clearly undesirable, the behaviors required to maintain lower weight have become increasingly costly, and some individuals may rationally choose behaviors that lead to excess weight.

On potential solutions, Finkelstein was skeptical that information campaigns alone would significantly change behavior, since most people already know or could know that certain habits are unhealthy. He saw greater promise in interventions that alter the cost-benefit calculus -- making healthy behaviors cheaper and easier while increasing the cost of unhealthy ones. He pointed to research showing that even modest financial incentives (about $7 per pound lost) can produce short-term weight loss.

Regarding the government's role, Finkelstein cautioned that using the high costs of obesity to justify public interventions creates an internal logic problem -- such interventions must themselves be cost-saving, and genuinely cost-saving obesity interventions are essentially nonexistent. He suggested the government would be better served by reviewing existing policies that may inadvertently promote obesity, such as agricultural subsidies, zoning policies that encourage automobile use over walking, and insurance structures that favor treatment over prevention. He also expressed optimism that private-sector technology and innovation would ultimately play a significant role in addressing obesity.

Discussion Highlights

In the question-and-answer session, Ginsburg asked Clancy about how many people counted in chronic condition statistics have well-controlled conditions. Clancy noted that health expenditures are highly concentrated -- roughly 20 percent of the population accounts for about 72 percent of health care spending -- and the majority of those individuals have multiple chronic illnesses. She acknowledged that understanding how many people are effectively managed remains an important research question.

When pressed on why obesity shows little socioeconomic variation within racial groups despite food prices being a key driver, Finkelstein explained that all consumers have experienced the same broad price declines, so rising obesity has affected everyone. He noted that wealthier populations may have actually seen slightly faster increases because they have more resources to spend on calorie-dense food and sedentary entertainment.

An audience member from the Maryland Health Care Commission observed that chronic conditions consumed about 70 percent of health care dollars as far back as the early 1960s, questioning why the issue has only recently attracted intensive policy attention. Clancy attributed the renewed focus to several factors: the work of researchers like Ed Wagner in making explicit what health care could do, the growing magnitude of the problem as life expectancy increased, and the accumulating critical mass of evidence.

On the elimination of physical education from many schools, Finkelstein suggested that government has a clear consumer-protection role for children -- as it does with age-restricted tobacco and alcohol -- and should ensure children receive physical activity and healthy meals at school before they are old enough to make independent lifestyle decisions. Regarding disease management programs, Clancy noted that identifying which patients are most likely to benefit and how to address the needs of people with multiple conditions when programs are organized around single diseases remain active research challenges.

Sources and Further Reading

CDC National Center for Chronic Disease Prevention and Health Promotion — Federal data on chronic disease prevalence, obesity trends, cardiovascular risk factors, and prevention strategies referenced in this conference.

AHRQ Medical Expenditure Panel Survey (MEPS) — The national survey data cited by AHRQ Director Clancy on chronic condition prevalence and health care spending concentration.

CMS Chronic Conditions Data — Medicare data on chronic condition spending, multiple chronic conditions among beneficiaries, and quality of chronic disease care.

NIH Obesity Research — National Institutes of Health research on obesity, its economic and health consequences, and evidence-based interventions.

Commonwealth Fund: Chronic Disease Management Research — Research on chronic disease management programs, patient self-management, and health system improvements for people with multiple chronic conditions.

Health Affairs: Chronic Disease Policy Research — Peer-reviewed studies on chronic disease costs, prevention economics, and health system reform efforts to improve chronic care delivery.