1. 1 Making Health Care More Affordable: A Bipartisan Reform Agenda Around Chronic Disease Prevention and Management Kenneth E. Thorpe Emory University and Executive Director, Partnership to Fight Chronic Disease kthorpe@sph.emory.edu

2. 2 Health Care Reform Debate in 2009 Largely unsuccessful in enacting reforms nationally for the past 60 years Largely unsuccessful in enacting reforms nationally for the past 60 years Many lessons from our last national effort in 1993-94 Many lessons from our last national effort in 1993-94 THIS TIME WE NEED A: THIS TIME WE NEED A: New message New message New strategy New strategy A bipartisan approach A bipartisan approach

3. 3 System Reforms Need to make health insurance more affordable for the 250 million Americans with health insurance Need to make health insurance more affordable for the 250 million Americans with health insurance 96% of those who voted in 2006 had health insurance 96% of those who voted in 2006 had health insurance Their number one concern and anxiety was over the cost of health care and whether their employer (or the state) was going to continue to provide coverage Their number one concern and anxiety was over the cost of health care and whether their employer (or the state) was going to continue to provide coverage

4. 4 Six Unhealthy Truths Tell the Story of the Rise of Chronic Disease and Its Impact on Health and Health Care in the U.S.

5. 5 133 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 #1: Chronic diseases are the #1 cause of death and disability in the U.S.

6. 6 During 2007, the U.S. spent over $2.2 trillion on health care Truth #2: Patients with chronic diseases account for 75% of the nations 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

7. 7 Truth #3: Two-thirds of the increase in health care spending is due to increased prevalence of treated (primarily) chronic disease ~$211 billion Level 0f health spending among the noninstitutionalized 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

8. 8 % of Adult Population Treated, By Medical Condition, 1987-2005: Rapid Rise in Disease Prevalence Medical Condition 1987 % 2005 % Mental Disorders HyperlipidemiaHypertensionDiabetes Pulmonary Conditions (OPD, Asthma) Lupus/Other Related Arthritis Back Problems Upper GI Heart Disease 5.5%1.5%13.6%4.0%9.5%4.857.8%5.4%3.8%8.1%18.8%14.4%22.0%8.0%18.4%6.0%13.6%13.2%10.7%9.5%

9. 9 Why Does Treated Prevalence Rise Over Time? Rise in the incidence of disease Rise in the incidence of disease Technology (treatment expansion) Technology (treatment expansion) Changes in clinical thresholds (metabolic syndrome) for treating asymptomatic patients Changes in clinical thresholds (metabolic syndrome) for treating asymptomatic patients Better disease detection and screening (both by patients and physiciansdepression) Better disease detection and screening (both by patients and physiciansdepression) Longevity Longevity Others? Others?

10. 10 Truth #4: The doubling of obesity between 1987 and today accounts for 20 to 30% of the rise in health care spending No data<10%10%-14% Percent of U.S. Adults Who are Obese* 1985 *BMI 30, or ~ 30 lbs overweight for 5 4 person

11. 11 No data<10%10%-14%15%-19%20%-24%25%-29%>30% *BMI 30, or ~ 30 lbs overweight for 5 4 person Truth #4: The doubling of obesity between 1987 and today accounts for 15 to 30% of the rise in health care spending If the prevalence 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 overweight has tripled since 1980 Percent of U.S. Adults Who are Obese* 2005

12. 12 Diabetes Prevalence among U.S. Adults Aged 20 - 74 BMI Category Obese III (> 40) Obese II (35-40) Obese I (30 -35) Overweight (25 -30) Normal / underweight (<25) Total 5.03% 8.83% Age and sex adjusted (from Gregg, 2005)

13. 13 The Centers for Disease Control and Prevention (CDC) estimates… The Centers for Disease Control and Prevention (CDC) estimates… 80% of heart disease and stroke 80% of heart disease and stroke 80% of type 2 diabetes 80% of type 2 diabetes 40% of cancer 40% of cancer …could be prevented if only Americans were to do three things: …could be prevented if only Americans were to do three things: Stop smoking Stop smoking Start eating healthy Start eating healthy Get in shape Get in shape Management of chronic disease could also be significantly improved: Chronically ill patients receive only 56% of the clinically recommended preventive health care services Management of chronic disease could also be significantly improved: Chronically ill patients receive only 56% of the clinically recommended preventive health care services Truth #5: The vast majority of cases of chronic disease could be better prevented or managed

14. 14 National survey conducted in April 2007 on Americans views of chronic disease and its impact on health and spending Truth #6: Many Americans are unaware of the extent to which chronic disease harms their health – and their wallets Percent of Americans who believe chronic disease is responsible for the following percent of death and health spending in the U.S. Percent answering: DeathSpending Less than 10% 36 10% but less than 20% 88 20% but less than 30% 1412 30% but less than 40% 1510 40% but less than 50% 1512 50% but less than 60% 1211 60% but less than 70% 79 70% but less than 80% 87 80% but less than 90% 43 90% to 100% 34 Not sure Not sure1018 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

15. 15 Slowing the Growth in Healthcare Spending and Managing the Level of Spending Need to broaden the debate to focus on rising population disease prevalence. Current focus on high deductible plans not likely to affect these trends, and could make matters worse for chronically ill patients. Need to broaden the debate to focus on rising population disease prevalence. Current focus on high deductible plans not likely to affect these trends, and could make matters worse for chronically ill patients. Need to better manage care provided to the chronically illthey acct for 75% of the spend, receive less than optimal care. This will require us to change how we pay for services. It will also require us to modernize our health care IT and delivery systemsthis will not happen absent major changes in how payers like Medicare pay providers to treat the chronically ill. Need to better manage care provided to the chronically illthey acct for 75% of the spend, receive less than optimal care. This will require us to change how we pay for services. It will also require us to modernize our health care IT and delivery systemsthis will not happen absent major changes in how payers like Medicare pay providers to treat the chronically ill.

16. 16 Common sense approaches for slowing the growth in spending 1. Key Issues: Slow rise in treated disease prevalence through, Slowing the rise in obesity prevalence among children and adults. Slowing the rise in obesity prevalence among children and adults. Need to broaden discussion of reform to include primary care, primary prevention. Should be a center piece of any cost containment effort. Need to broaden discussion of reform to include primary care, primary prevention. Should be a center piece of any cost containment effort. 2. Policy Tools School Based Interventions (both calories and intervention) School Based Interventions (both calories and intervention) New and effective health promotion, wellness, disease prevention programs available for all adults – perhaps a universal wellness and health promotion benefit for all New and effective health promotion, wellness, disease prevention programs available for all adults – perhaps a universal wellness and health promotion benefit for all Financial incentives to participate Financial incentives to participate 3. Modernize our health care delivery system. Need modern IT infrastructure and integrated delivery models to address both the clinical and cost issues to care for the chronically ill Need modern IT infrastructure and integrated delivery models to address both the clinical and cost issues to care for the chronically ill

17. 17 Summary Changes outlined above requires fundamental restructuring of the US health care delivery system Changes outlined above requires fundamental restructuring of the US health care delivery system Attacking key drivers of rising spending which require a broader set of policy options. Attacking key drivers of rising spending which require a broader set of policy options. Need to focus on improving the care for chronically ill patients Need to focus on improving the care for chronically ill patients Develop national strategy for addressing rise in treated disease prevalence Develop national strategy for addressing rise in treated disease prevalence Devote resources to developing effective health promotion, wellness programs for use in schools, and the worksite. Devote resources to developing effective health promotion, wellness programs for use in schools, and the worksite.