The Rise of Chronic Diseases In America - The Future of Healthcare Delivery

Here are some numbers to contemplate. In the United States, there are about 465,000 preventable deaths per year, 395,000 from high blood pressure, 216,000 from obesity, 191,000 from inactivity, 190,000 from high blood sugar levels, and 113,000 from high cholesterol. These causes of death are mostly although not exclusively related to our behaviors and lifestyles. The United States ranks thirty-ninth for infant mortality and thirty-sixth for life expectancy, yet, we are first for per capita spending on health care. Something is terribly wrong with this picture.

We cannot control many factors that affect our health. We cannot change our parents, many of us live in poverty where exposure to toxins such as lead paint is prevalent and food available for purchase is less than satisfactory, and many of us have less-than-adequate access to good health care. But among the factors that we can control and change are our behaviors. All too many Americans still smoke; many drink alcohol to excess and, more troubling, drive while intoxicated; and many do not wear seat belts. Although most of us have fluoridated water, many still have poor dental hygiene. We eat to excess and eat foods with little nutritional value, and we exercise all too little. We are on the verge of epidemics of diabetes, cardiovascular disease, and more because of these behaviors. It will not do to blame the fast-food industry, the soft drink manufacturers, or the cigarette or beer manufacturers without also taking personal responsibility for consuming their products. But we do need a national campaign to teach everyone what a healthy lifestyle is all about and educational programs to assist with smoking cessation, weight control, good nutrition, and stress management. We also need meaningful monetary incentives in the form of insurance premium reductions to help us change our behaviors. Our medical care system is poorly designed to deal with this crisis and certainly is not incentivized to tackle it. Generalist physicians are not paid to spend time with patients to teach them about diet and exercise or the benefits of not smoking. Nor is anyone else paid to do it! We need a political initiative to address the issues and changes in compensation for health-care professionals that in turn will allow them to assist patients in ways that will have a major impact on health into the future. For example, primary care physicians need to be incentivized to spend time on preventive medicine (for example, counseling for tobacco cessation, nutrition, weight loss, and exercise) and to coordinate the care of their patients with chronic illnesses who must visit many specialists and undergo many diagnostic tests or procedures. Both efforts would markedly improve the quality of care, improve patients’ health, and reduce expenditures. The goal is all about adjusting the financial incentives for both providers and the population at large.

We need to appreciate how diseases have changed dramatically over the past century and more and thus how we must change our approaches to deal with the diseases that are now rampant. At the beginning of the twentieth century when my grandfather started his medical practice, the most common causes of death were pneumonia and tuberculosis, both of which are far down the list today. Indeed, for most of human history, infectious diseases and malnutrition were the major reasons why the average expectancy was only about thirty years. Then with the industrial age came sanitation, the first vaccines, and better nutrition with a consequent decline in infant mortality and a rise in life expectancy. But then smoking and dietary changes led to more cardiovascular diseases and cancers by the mid-twentieth century and beyond. Now, although smoking has declined, obesity and lack of exercise have led to rapid increases in diabetes, heart disease, stroke, and high blood pressure plus joint disease, cancers, sleep apnea, asthma, and many other chronic illnesses that last a lifetime.

Unless and until we as a society deal with our behaviors, our health status will not improve. Yes, access to medical care is important, and it is beyond belief that our country does not afford everyone easy and affordable access to medical care. As a society we also need to offer everyone a good education so that they can be productive and increase their standard of living. Our insistence on a diet high in fat and sugar, our lack of exercise, our persistent use of tobacco, and our unwillingness to do the simple things in life such as brush our teeth, however, will condemn many of us to a life of poor or at least inadequate health. We individuals need incentives to change our habits and behaviors. A reduction in health insurance premiums for either engaging in good behaviors or taking action to lose weight, stop smoking, and start exercising would be a positive incentive.

As to medical care, our quality is fairly good, although it is certainly not as good as it could or should be. The problem is twofold. First, our medical care system does not deal with health; it concentrates on illness, or “disease and pestilence.” Second, we poorly manage the more complex illnesses that are chronic, such as diabetes, heart failure, and cancer.

According to a report for the World Economic Forum released in September 2011,

“Non-communicable diseases have been established as a clear threat not only to human health, but also to development and economic growth. Claiming 63% of all deaths, these diseases are currently the world’s main killer. Eighty percent of these deaths now occur in low- and middle-income countries. Half of those who die of chronic non-communicable diseases are in the prime of their productive years, and thus, the disability imposed and the lives lost are also endangering industry competitiveness across borders.”

These chronic illnesses have become much more common and consume a huge amount of the total cost of health care. The Milken Institute quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions, and mental disorders. Here are some of the key findings:

More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases. The total impact of these diseases on the economy is $1.3 trillion annually. On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases and $4.2 trillion in treatment costs and lost economic output. Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year.

To me the important point is that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.”

The fundamental problem is that our delivery system was designed to deal with acute problems, not chronic ones. A single physician can treat most acute illnesses such as an ear infection. Chronic illnesses, however, require a team approach with well-coordinated care to ensure quality outcomes, safe care, and reasonable or at least not excessive costs. Indeed, good care coordination can reduce the number of doctor visits, procedures, tests, and even hospitalizations required, resulting in better care for less cost. But we do not have this setup today.

Instead, our system is a medical care system, not a health-care system. Further, good care is only good if a person can access it, and we clearly lack in access given that 47 million Americans are without insurance and many more are underinsured. America is the only country in the developed world that does not ensure all its citizens will have access to basic medical care and that their catastrophic needs will be covered. The current reform bill, the Patient Protection and Affordable Care Act, will add about 31 million to the insurance rolls so it will make a big dent in the problem. Add the paucity of general or primary care physicians in the inner cities and rural areas, however, and it becomes apparent that access to care by those who most need it is deficient, whether or not they have insurance. Those without insurance or ready access to a provider or both have worse health, and ultimately their poor health status increases all of our costs when these individuals end up in the ER with a major problem that could have and should have been treated simply and cheaply much earlier.
Further, most of us find that we get too little time with our physician when we do have an office visit, and we leave feeling that we were not listened to, not understood, and not certain whether the plan of care was really the best it could be. Add to all of this tension the frustration of dealing with the insurance companies, the paperwork, the phone calls, the time to get an appointment, and the lack of coordinated care among providers, and it is no wonder that medical care is nowhere near what it could be and not what it should be, especially given that 17 percent of our gross domestic product (GDP) is committed to health care.

The Critical Issues Confronting Health-Care Delivery and Health-Care Reform
Following are the major delivery and reform issues that need to be addressed. Any effective reform package needs to address the delivery issues in order for it to have a really helpful and cost-neutral impact that is satisfying to patients and providers alike.

Delivery Issues

    • Shift the delivery model to focus on complex, chronic illnesses.
    • Establish good care coordination for those with chronic illness and catastrophic disease or injury.
    • Encourage more physicians to enter primary care (and certain specialties such as general surgery).
    • Offer sound preventive care and wellness management.
    • Shift from the diagnose and treat paradigm to one of prediction and prevention.

Reform Issues

    • Access—ensure quality health care for all regardless of ability to pay by giving them insurance and ensuring that providers are available.
    • Insurance—set mandates, community ratings, preexisting conditions, and premium variations based on behaviors, such as smoking, weight, and exercise.
    • Payments—reconsider how physicians, hospitals, and other providers receive payment, that is, per a visit or procedure or via capitation or by bundling with measures of quality and safety.
    • Delivery—reorganize how medicine is delivered to each of us (intimately tied to payment reform).
    • Costs—reduce presumably as a result of the preceding reforms if properly conceived and implemented.

 

 

Last Modified: December 13, 2011


Copyright (c) Stephen C. Schimpff, MD