When the famous bank robber, Willie Sutton, was asked why he robbed banks, he replied, “That’s where the money is.” In healthcare, the money is in chronic illnesses. These consume about 75-85% of all dollars spent on medical care. The need is to focus there.
The diseases that a physician sees today are markedly different than in years past. Decades ago, most illnesses were acute (or temporary, such as pneumonia and appendicitis) but today the vast majority are chronic (heart failure and chronic lung disease that stick with you for life).
Chronic disease is transforming health, medical costs and the delivery of care. Diseases such as diabetes, heart failure, emphysema, and cancer are chronic. Once developed, they usually last a lifetime, are difficult to manage and expensive to treat. Chronic illnesses, once rare, are becoming commonplace. They are responsible for the vast majority of health care costs but are, to a large degree, preventable.
Chronic illnesses have two primary antecedents — aging and adverse lifestyles. There has been a remarkable increase in average lifespans and an increasing percentage of those who live a longer time. With aging comes certain impairments, including impaired vision, hearing, mobility (osteoarthritis), bone strength (osteoporosis with fractures), dentition (and with it impaired nutrition) and cognition. Good diet and exercise will limit osteoporosis and joint damage, dental hygiene will limit loss of teeth, avoidance of excessive noise can lessen hearing loss, avoidance of excessive ultraviolet rays from the sun can limit the development of cataracts, and physical and mental exercise along with a good diet can stave off normal cognitive decline. But as we age, many of these impairments, even with excellent self-care, will develop and progress over time.
But with aging also comes an increased frequency of chronic illnesses – cancer, heart disease, arthritis, diabetes, and Alzheimer’s. These diseases for the most part are mostly related to our lifestyles over a lifetime. Poor diet, lack of exercise, chronic stress, inadequate sleep, tobacco, etc. all conspire over the years to finally manifest as disease. And it is these diseases that most often cause death today.
Author’s Image from Fixing The Primary Care Crisis based on Jones, et al, “The Burden of Disease and the Changing Task of Medicine” in the New England Journal of Medicine.
As reviewed in the prior article in this series, in 1900, the three most common causes of death in the U.S. were typhoid, tuberculosis and pneumonia – all infectious diseases. Now, the three most common causes of death in the U.S. are cardiovascular, cancer and lung disease – all chronic illnesses, mostly lifestyle-related and all largely preventable.
Not surprisingly, obesity and obesity-related diabetes have also emerged as major predisposing factors to chronic illness and are climbing the list of primary causes of death.
The most important underlying drivers of these chronic illnesses as of 2000, according to a Centers for Disease Control and Prevention (CDC) report in the Journal of the American Medical Association, are tobacco use, poor dietary habits, lack of exercise and alcohol abuse – all modifiable behaviors. They commented, looking to the future, “These analyses show that smoking remains the leading cause of mortality [in 2000]. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.”
In the ensuring twenty years, obesity has become epidemic and diabetes is rapidly following. They lead to more heart disease, kidney failure, strokes, and dementia.
The striking reduction of acute, infectious diseases is a testament to the successful collaboration of both science and society in its development and adoption of sanitation, safe water and food, hygiene, antibiotics and immunizations during the last 100 plus years. Safer work environments mean less environmental exposures, trauma and injury.
In addition, the presence of Alzheimer’s and suicide among the common primary causes of death today illustrates the complexity of how aging and mental health are impacting illness and survival. They further signal the reality that mental health has become an entirely new segment of concern in the ever-growing list of chronic diseases in our society. Although present for decades, the appearance of the Covid pandemic amplified the diseases of despair – alcoholism, opioid addiction and overdose deaths.
Older people have more chronic illnesses than younger individuals. But this is not necessarily due to the aging process itself. Yes, older individuals have various impairments, including vision, hearing, mobility and mental capabilities, but the important chronic illnesses such as heart disease, cancer, chronic lung and kidney disease and diabetes are related to long-term effects of lifestyle factors. For example, lung cancer occurs, on average, at age 72, but the steps leading to it began in someone’s teens and twenties when smoking began. Heart disease is more common among the elderly, but the process of creating atherosclerosis begins at a young age with the ingestion of the wrong foods, lack of exercise and good dose of chronic stress over a lifetime. Restated, it takes many years for coronary artery plaque to build up sufficient to cause a heart attack. Just because it occurs after age 65 does not imply that it was related to aging. Rather, it just says that the person has lived long enough for the progressive effects of poor and excessive diet, lack of exercise and related obesity, stress and smoking combined with genetic predispositions to finally have the effect of causing overt disease. Of course, the aging process diminishes the immune system and other body protective mechanisms so that acute and chronic diseases can more easily progress and manifest themselves.
This trend toward prolonged, chronic diseases now poses a new commensurate challenge for both science and society.
The magnitude of the task at hand was illustrated 2007 by the Milken Institute in An Unhealthy America: The Economic Burden of Chronic Disease. They evaluated cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental disorders. The study noted that nearly one half of Americans had one or more chronic illnesses and that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.”
Industry has also recognized that 75 percent of their healthcare costs go to the care of just a few diseases – each chronic and each largely preventable. Commercial insurers, primarily dealing with those under age 65, report that 70-85 percent of paid claims are for chronic illnesses. For Medicare, 85 percent of enrollees have at least one chronic illness, while more than 50 percent of enrollees have three or more chronic illnesses that require them to consume an average of 5 to 7 prescription medications per day.
In 2018 the Milken Institute put out a new comprehensive report entitled “The Costs of Chronic Diseases in the United States.” Here are the summary conclusions: “Americans’ chronic health problems and diseases not only come at the expense of individuals well-being; they also constitute a massive burden on the U.S. economy. When including the costs of lost economic productivity, the total costs of the varying types of chronic disease in the U.S. is equivalent to almost one-fifth of the American economy. In 2016, the total costs in the U.S. for direct health care treatment for chronic health conditions totaled $1.1 trillion—equivalent to nearly six percent of the nation’s GDP. The most expensive conditions in terms of direct health care costs are cardiovascular, diabetes, Alzheimer’s, and osteoarthritis.”
Milken emphasizes the importance of obesity on the development of chronic diseases. “Obesity is by far the greatest risk factor contributing to the burden of chronic diseases in the
U.S. The prevalence of obesity in the U.S. population has increased steadily since the 1960s.
In 2016, diseases caused by obesity and being overweight accounted for 47.1 percent of the total
cost of chronic diseases in the U.S. [italics mine]—responsible for $480.7 billion in direct health care costs, plus $1.24 trillion in indirect costs related to lost economic productivity. The total cost of chronic diseases due to obesity in 2016 was $1.72 trillion—equivalent to 9.3 percent of the U.S. GDP that year.”
Our medical care system has developed over centuries around the process of diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gives an antibiotic for the pneumonia and the patient gets better. The surgeon cuts out the gall bladder or the appendix and the patient is cured. One patient, one doctor.
But patients with chronic illnesses need a different approach to care. They need long-term comprehensive care, not episodic care. They need a physician with the time and expertise to give continuing attention to all aspects of their care. This physician, preferably a PCP, has the expertise to do most of the care required. But when specialists are needed, the PCP needs to serve as the orchestrator of a multi-disciplinary team with the PCP as quarterback to manage the myriad physician specialists and other health care providers, tests, and procedures to allow for a unified, coordinated care approach. Only when the PCP has the time to give most of the needed care related to chronic diseases and has the time for this type of coordinated approach, will care be maximized yet costs reduced.
This requires a new paradigm in management, incentives, responsibilities, and compensation for physicians and new responsibilities and incentives for patients as well. The key to this new paradigm is the primary care provider. He or she is well trained and experienced in chronic disease management. But to do this, the number of patients under care by each PCP must be reduced from about 2500-3000 to no more than 500-800. At this level, the provider can have the time needed to listen, prevent, diagnose, treat and think. This will reduce the excessive use of specialists, tests and procedures and the reflex to hand out a prescription when a lifestyle change would be both more appropriate and more effective. And when a specialist is needed, the PCP will have the time to personally call the specialist and explain exactly why he is referring the patient and ask for a prompt appointment. This approach has been proven, as explained in Fixing The Primary Care Crisis , to dramatically improve quality, reduce visits to specialists, ERs and hospitals, reduce the costs of care while improving patient satisfaction, and reducing doctor frustration and burnout.
But dramatically improving care for those with chronic diseases, valuable as that will be, is only part of the equation. Another critical, indeed most important, aspect is prevention which must start with maintaining health and wellness, something America does poorly — at best. A later article in this series will address wellness, health and prevention.