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

Chronic Disease Was Reshaping American Health Care, but the System Was Not Keeping Up

By 2005, roughly 60 percent of American adults had at least one chronic health condition, and more than one in four had two or more. Heart disease, diabetes, asthma, depression, arthritis -- these ongoing illnesses were driving the bulk of health care spending and accounting for the leading causes of death. Yet the U.S. health system remained organized around acute, episodic care: good at treating a heart attack, but poorly equipped to prevent and manage the underlying disease that caused it. A Center for Studying Health System Change (HSC) conference in July 2008, summarized in Issue Brief No. 125 (November 2008) by Alwyn Cassil, brought together researchers and practitioners to examine why chronic conditions were surging, what was being done about it, and where the biggest gaps remained.

A System Built for the Wrong Century

In one sense, the rise of chronic disease reflected a success story. A century earlier, average life expectancy in the United States was 47 years, and the leading killers were infectious diseases -- pneumonia, influenza, tuberculosis -- along with accidents and childbirth complications. Advances in public health, industrial safety, and medicine had pushed life expectancy to 78 years by the time of the conference. People were living long enough to develop the heart disease, cancer, and stroke that now topped mortality tables.

But the health care delivery system had not adapted to the shift. As HSC President Paul B. Ginsburg noted in moderating the conference, the system remained geared toward acute episodes of care. Treating a heart attack was something American medicine did well; preventing and managing the underlying cardiovascular disease was another matter entirely. The reimbursement structure reinforced the problem, rewarding high-tech procedures after complications occurred rather than the ongoing primary care and preventive work that might have avoided them.

The Evidence Gap for Multiple Chronic Conditions

Panelist Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, pointed to a critical knowledge gap. While substantial research existed on how to manage individual chronic illnesses like diabetes or heart disease in isolation, the evidence base for managing patients with multiple simultaneous conditions was thin. More than one in four Americans had two or more chronic illnesses, and many had three, four, or five. For those patients, interactions between diseases and between treatments created layers of complexity that single-disease clinical guidelines could not address.

The challenge was compounded when one of those conditions was a mental health disorder, which was common among patients with the highest disease burdens. Multiple conditions meant multiple medications, multiple providers, and -- as Clancy put it -- so many clinicians involved that it was hard to imagine a common script coordinating all of them. The system was getting better at acute intervention, she noted, with complication rates falling and mortality improving for procedures. But the record on getting patients to adhere to recommended medications and self-care regimens after discharge had not improved at all.

The Economics Behind Obesity's Rise

Two-thirds of Americans were overweight or obese by this point, and the prevalence of obesity had more than doubled in three decades. Economist Eric Finkelstein of RTI, author of The Fattening of America, framed obesity as an economic phenomenon rather than purely a personal failing. The monetary price of food had fallen, and the effort required to acquire it had dropped even further -- cheap, calorie-dense food was everywhere. At the same time, the caloric expenditure side of the equation had shifted dramatically. Leisure time that once involved some physical activity was increasingly consumed by DVDs, the internet, cable TV, and computer games. On-the-job "accidental exercise" had all but vanished as occupations became mechanized.

Finkelstein pointed to an interesting wrinkle: medical advances like statin drugs had actually reduced some of the health consequences of obesity over time. Today's obese population had a better cardiovascular disease profile than normal-weight individuals from several decades earlier. The combination of cheaper food, less physical activity, and lower health costs of being obese had created conditions where rising obesity rates were an entirely predictable economic outcome.

But Finkelstein cautioned against using obesity's high cost as automatic justification for public interventions, arguing that publicly funded, cost-saving obesity programs simply did not exist at the time. Instead, he suggested government should examine how existing policies -- agricultural subsidies, zoning regulations that favored automobile transportation -- may have contributed to the problem in the first place.

Medicaid's Dual-Eligible Population: Crisis or Opportunity?

Nowhere did chronic conditions hit harder than among the approximately 7 million people dually eligible for both Medicaid and Medicare. Panelist Melanie Bella of the Center for Health Care Strategies reported that dual eligibles accounted for roughly 42 percent of Medicaid spending and 25 percent of Medicare spending. Among the costliest 1 percent of Medicaid enrollees, 83 percent had three or more chronic conditions and 60 percent had five or more.

Bella argued this population represented an enormous opportunity rather than just a crisis. The combined purchasing leverage of Medicaid and Medicare, together with the complexity and cost of the patient population, made it a prime testing ground for chronic care innovations. But states faced serious obstacles. Most high-need beneficiaries received care through fragmented fee-for-service arrangements. Reimbursement rates were too low to support complex care management. Medicaid's financing structure created pressure for immediate cost savings, making it hard to invest in long-term solutions. And the split between Medicare (which pays for hospital care) and Medicaid (which covers nursing homes) produced perverse incentives: if better care coordination kept a Medicaid nursing home patient out of the hospital, the savings went to Medicare, not to the Medicaid program that had invested in the coordination.

Workplace Wellness: Popular but Often Poorly Executed

Employers were increasingly adopting health promotion and wellness programs, but panelist Ron Goetzel of Emory University questioned whether most were doing it well. A growing body of evidence suggested that well-designed, evidence-based workplace programs could improve worker health, reduce disease risk, lower absence and disability costs, and boost productivity. The problem was that many employers were implementing programs with little understanding of what actually worked. Best practices existed but were not being widely disseminated, and large-scale studies evaluating different interventions were lacking.

Redesigning Care Delivery Around Chronic Needs

Panelist Michele Heisler, M.D., of the University of Michigan and the VA, laid out the case for fundamentally restructuring how physician practices handle chronic disease. Research consistently showed the system did a poor job of getting chronic disease under control. Patients were frequently not on the right medications at the right doses, and even when correctly prescribed, only about half took their medications as directed. The numbers were worse for diet and exercise recommendations. The costs of medication nonadherence alone -- counting avoidable emergency visits and preventable hospitalizations -- exceeded $100 billion annually.

Heisler argued that patient self-management was the linchpin of effective chronic care. Outcomes depended critically on what patients did between office visits -- taking medications, monitoring symptoms, making dietary changes, exercising. But current care systems were not set up to support this. Drawing on the Wagner Chronic Care Model, she outlined four areas where practice-level redesign was needed: delivery system design (who is on the care team and how they interact with patients), decision support (making evidence-based care happen consistently), clinical information systems (capturing and using data for clinical care), and self-management support (helping patients live with their conditions and change behaviors).

The Patient Engagement Challenge

Panelist Kristin Carman of the American Institutes for Research highlighted a further complication: patients and the health system often operated with different assumptions. When providers talked about clinical guidelines and evidence-based care, many patients heard restrictions on their choices -- inflexible, one-size-fits-all rules designed to protect everyone but the patient. Carman's research found that about three-quarters of survey respondents said they were trying to make a lifestyle change to improve their health, but nearly all of them -- whether the change was large or small -- reported finding it hard or very hard.

This disconnect pointed to a broader communication problem. Consumers generally believed that more care meant better care, making it difficult to accept evidence suggesting otherwise. The point was not that patients lacked the capacity to understand evidence-based medicine -- of course they could. But health systems and employers needed to understand where patients actually were in their thinking before they could communicate effectively about behavior change and self-management.

Conference Participants

The conference was moderated by Paul B. Ginsburg of HSC. Panelists included Melanie Bella of the Center for Health Care Strategies; Kristin Carman of the American Institutes for Research; Carolyn Clancy, M.D., of the Agency for Healthcare Research and Quality; Eric Finkelstein of RTI; Ron Goetzel of Emory University and Thomson Reuters; and Michele Heisler, M.D., of the University of Michigan and the Department of Veterans Affairs. The conference was co-sponsored by the Pharmaceutical Research and Manufacturers of America (PhRMA), DMAA: The Care Continuum Alliance, and the American College of Preventive Medicine.

Sources and Further Reading

Agency for Healthcare Research and Quality (AHRQ) -- Federal agency focused on health care quality, safety, and effectiveness research.

CDC -- Chronic Disease Prevention -- Federal data and programs on chronic disease.

CMS -- National Health Expenditure Data -- Official data on U.S. health spending trends.

Health Affairs -- Peer-reviewed health policy research.

Robert Wood Johnson Foundation -- Health policy research and programs.