Karen Appold

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Diabetes, especially Type 2 diabetes, has a split personality. It is one of the most common diseases in the United States; currently 1 in 10 Americans has Type 2 diabetes, and some projections show that proportion increasing to 1 in 3 by midcentury. Diabetes is also among the country’s costliest diseases. Medical expenditures for people who have diabetes are $16,752 per year, on average, of which about $9,600 is attributed to diabetes, according to the American Diabetes Association. Those expenditures are approximately 2.3 times higher than those, on average, for people without diabetes.

The dire facts and figures about diabetes could fill pages. But diabetes is also one of the most preventable and, under the right circumstances, manageable diseases. Diet and exercise can lower the risk of getting prediabetes, which is defined by A1C and blood sugar levels that are above normal but shy of those that would indicate diabetes. Doses of healthy eating and physical activity can lower the risk of prediabetes worsening and crossing the line into full-fledged diabetes. Once people have diabetes, lifestyle changes, medications and monitoring for neuropathy, among other things, can lower the risk of developing complications such as lower-limb amputations and cardiovascular disease.

Payers and others are keeping tabs on the efforts to prevent and control diabetes. “Quality metrics associated with diabetes have gained increased national support, and efforts to improve care have been associated with improved control of blood glucose in acute care settings,” says Sally O. Gerard, D.N.P., RN, CDE, CNL, a diabetes educator at Stamford Health, a healthcare system in Stamford, Connecticut. “A more focused analysis of costs associated with diabetes would strengthen efforts for organizational support of diabetes improvement initiatives.”

Here’s a look at how three healthcare organizations have addressed the management of diabetes and its related costs.

The Geisinger Health System is an integrated delivery system headquartered in Danville, Pennsylvania, a small town about 150 miles northwest of Philadelphia. For years, Geisinger has enjoyed a reputation for delivering high-quality, relatively low-cost care — a city on the hill amid a healthcare system that teems with expense and waste. As such, it’s not surprising that Geisinger has an inventive, well-rounded program for tackling diabetes.

“Since both of these conditions (diabetes and prediabetes) can be managed and even reversed with lifestyle changes, we have directed our efforts to programs that support long-term behavior changes that support a healthy lifestyle,” says Allison Hess, Geisinger’s vice president of health and wellness. “These programs complement existing clinical interventions targeted at diabetes management.”

Almost two decades ago, the health system started a diabetes care management program led by registered nurses who were also certified diabetes educators. The program combined education and glucose monitoring to improve diabetes management. Over the years, the diabetes programs have evolved, and diabetes educators are now part of a larger care team of primary care providers, pharmacists, health coaches and clinical nutritionists, among others. The team closely monitors patients. Beyond managing blood glucose and A1C levels, the groups adjust medications and guide patients through managing their disease themselves as much as possible.

Geisinger also has an innovative outcomes-based wellness program, including diabetes management, for its employees. The program was designed to help employees maintain and enhance their well-being through comprehensive benefits, health education and resources. The flagship is myHealth Rewards, a wellness program that provides discounts on insurance costs as incentives for members who reach certain health goals. The program is voluntary and participation is not 100%, so Geisinger conducted a clinical trial last year to test which email strategy is most effective at getting people to join.

For several years now, the American Diabetes Association has put a lot of effort and money into bringing prediabetes management into clinical and public health practice. The push was predicated in part on results of the Diabetes Prevention Program (DPP), a multicenter trial funded by the NIH that showed that diet and physical activity leading to weight loss could reduce the chances of developing diabetes by 58%. Various government programs have been launched to prevent diabetes and prediabetes, including a lifestyle change program recognized by the CDC. At Geisinger, 59% of myHealth Rewards participants with an AlC in the prediabetes range decreased their blood glucose to a normal level. Hess says the myHealth Rewards program has also reduced the incidence of unmanaged Type 2 diabetes as well as long-term complications of the disease, including stroke and heart attack.

Geisinger has also launched the Fresh Food Farmacy program to pilot “food as medicine” for people with Type 2 diabetes. The program provides 10 meals a week consisting of nutritious foods — whole grains, lean meats, fruits and vegetables — for patients who are food insecure and have uncontrolled Type 2 diabetes. The meals are paired with clinical support and education, including individual and group sessions. 

“Early indicators have shown promising results,” says Hess. Many patients have successfully lowered their A1C levels, fasting blood sugar, weight, triglycerides and low-density lipoprotein cholesterol. And how about costs? “We are currently looking at the financial outcomes, including emergency department visits and hospital admissions,” says Hess.

Geisinger also offers the CDC lifestyle program, which was inspired by the DPP trial results, to the community and employees. “When individuals participating in the program successfully achieve at least a 5% weight loss and at least 150 minutes of physical activity per week, they lower their risk of diabetes, heart disease and stroke,” Hess says.

Before social distancing, when in-person support was seen as a way of helping people stay the course on behavioral changes, Geisinger had encouraged participants to bring a caregiver, a family member or a friend to program meetings. More than 550 people have attended at least one session since the program was initiated in 2016. Fifty-six percent of participants lost weight, and of those, 33% lost at least 5% of their body weight.

In addition to achieving the highest tier of CDC recognition, Geisinger was recently approved as a Medicare DPP supplier. This allows for reimbursement for providing the DPP plan to at-risk Medicare beneficiaries. This is especially important because diabetes affects more than 25% of Americans ages 65 and older.

The state of Indiana is not a standout when it comes to diabetes. Based on deaths from the disease, it ranks 26th in the country. CDC data show that 10.4% of Indiana’s adults have been diagnosed with diabetes, which is higher than the national average of 8.5% but less than the proportion in Alabama (13.2%) and Arkansas (12.1%). But patients with diabetes have always represented a substantial proportion of physicians’ panels at Indiana University (IU) Health, says Victoria Bratcher, director of population health for the 17-hospital healthcare system headquartered in Indianapolis.

Three years ago, the system began a concerted, multispecialty initiative to address diabetes more effectively through comprehensive management programs. It zeroes in on social determinants of health and lifestyle factors that contribute to poor management of diabetes, such as barriers to healthy food, poor medication management and care coordination. One program weaves together diabetes education and pharmacy services to provide better coordinated care. IU Health’s education program is accredited by the American Association of Diabetes Educators and consists of two classes. One is a self-management class in which patients learn about diabetes and how to better manage their disease. 

The other is an individualized class with a dietitian who teaches patients about making healthful food choices and provides a meal plan designed to help keep diabetes well managed. (Foods with a low glycemic index can help avoid spikes in blood sugar levels.) While addressing the social determinants of health has been part of the program for a while, the focus on food is relatively new. Pharmacists are also on the care team, performing medication reconciliation and offering guidance to keep A1C levels under control. If these efforts are not effective in holding down someone’s A1C level, then the patient is referred to an endocrinologist, says Bratcher.

IU Health is also actively addressing food insecurity by addressing any education gaps and supplying food and other resources, such as transportation, as needed. Cost sharing can be a hurdle to taking medications that control diabetes, so an IU diabetes educator works with patients on finding ways to get prescription assistance from drug companies, if the patient is eligible, or copay cards.

The results of these efforts are showing up as solid progress if not quite show-stopping success. Since 2017, IU Health has increased the number of patients who are considered to have their diabetes well managed by 8.3%, according to Bratcher. Reductions in A1C levels among Medicare beneficiaries have resulted in a $80 to $100 per-member, per-month reduction in Medicare expenditures.

Three years ago, Stamford Health implemented a comprehensive set of care initiatives to improve patient outcomes, including mortality and length of hospital stay. Previous efforts had focused on improving glucose control in critically ill patients and were successful. The organization then turned its attention to the people who weren’t so ill.

“Decreasing length of stay is the most direct link to financial savings currently available for patients with diabetes, as poor glucose control can result in extended stays,” says Gerard, the diabetes educator. Stamford Health formed an interdisciplinary team to address improvements for noncritical patients in 2017. The institution employs quality initiatives set by the Society of Hospital Medicine that support comprehensive programs across the continuum of care.

Among its efforts was formation of a glycemic care committee comprising an interdisciplinary team of providers to address blood glucose control in noncritical patients. The team assessed opportunities to improve care based on glucose data, systems analysis, end-user feedback and patient outcomes.

The team also evaluated existing orders related to blood glucose control and updated them to provide more evidence-based treatments. Insulin is the primary medication used to treat hospitalized patients with diabetes, and in a hospital setting, it is considered a high-risk medication because it can push blood sugar levels too low. For patients requiring blood glucose testing, nurses were given standing physician orders to treat hypoglycemia with an appropriate medication. Parameters for the appropriate treatment were added to each patient’s electronic medical record to reduce wait times for treatment. These changes allowed nurses to move quickly to treat hypoglycemia. Stamford Health is also teaching nurses about the variances of blood sugar levels, insulin use and the timing of medications with meals to guard against any blood sugar-related dangers.

Karen Appold is a medical writer who lives in the Lehigh Valley area of Pennsylvania.

Articles

Three healthcare organizations provide models for managing the disease and keeping a close eye on the bottom line.

Tackling Diabetes While Curbing Costs

The COVID-19 outbreak has claimed more than 100,000 American lives, but evidence shows the disease has cut an especially wide swath of serious illness and death through African American communities in the United States. It is not entirely clear why, but healthcare experts say that complex, deeply rooted socioeconomic issues and healthcare inequities are the most probable explanation. 

Any number of  statistics reveal that COVID-19 has disproportionately affected African Americans. The COVID-19 database maintained by Johns Hopkins University shows that although African Americans represent only about 13% of the population in states reporting racial and ethnic information, they account for about 34% of total COVID-19 deaths in those states.

COVID-19 data from cities, states and health systems paint the same picture. 

In Chicago, 50% of cases and nearly 70% of deaths as of mid-April were black individuals, although African Americans comprise 30% of the city’s population. In Louisiana, roughly 70%  of those who have died of COVID-19 are African American, yet African Americans make up only 32.2% of the state’s population. The disproportion is similar in Michigan: 33% of the COVID-19 cases and 40% of COVID-19-related deaths have been among African Americans, but African Americans comprise only 14% of the state’s population. 

Researchers at Sutter Health, an integrated delivery system in California, reported in 

 in late May that among the system’s 1,052 confirmed COVID-19 cases, African Americans who tested positive for COVID-19 were twice as likely to be hospitalized as white people who tested positive (52.5% versus 25.7%) and, once admitted, were more likely to be transferred to the ICU (24.6% versus 10.7%).  However, when they looked at the 51 COVID-19-related deaths, they didn’t see a racial imbalance. 

An analysis by researchers from Epic, the electronic health record company, conveys the same basic message. Using their access to data on 23 million patients from 27 health systems in 16 different states, the Epic researchers found that African American patients accounted for 27% of COVID-19 hospitalizations and 22% of the deaths although they made up 12% of the sample population. 

Other minority groups have also been hit harder by COVID-19 than the general population, data show. In California, Latinos make up about 39% of the population but they accounted for 55% of the COVID-19 cases (34,809 of 63,505) in the California Department of Public Health’s ethnic group data. The proportion of deaths, 38% (1,329 of 3,504), however, was in line with the population proportion. In Arizona, 17% of the COVID-19 cases and 12% of the deaths were Native Americans, although they make up only about 5% of the population.


	An unknown biological or genetic factor could explain the disproportionate effect that COVID-19 has had on the African American community. But using race as biological or genetic category is hugely problematic and has been rejected by many researchers. Socioeconomic and healthcare inequities are a better explanation.  For generations, racist policies and program segregated African Americans into poor urban areas with limited access to education, employment opportunities, housing and healthcare services. One result is that African Americans are more likely to hold lower-paying jobs that require them to attend work in person rather than remotely and rely on public transportation, both of which make exposure to the virus more likely. People of color are more likely to work in lower-wage industries such as restaurants and hotels, notes Doug Wirth, president and CEO of Amida Care, a not-for-profit Medicaid special needs health plan in New York City. Stay-at-home and social distancing rules shut many of those business down. If they don’t bounce back, African Americans workers will be disproportionately affected. 

It’s also well documented that people in communities of color are far more likely to suffer from chronic diseases such as diabetes, asthma, obesity, hypertension, and heart disease that put people at higher risk for COVID-19, Wirth observes. When the Epic researchers looked at patients with no comorbidities, African Americans were still overrepresented among COVID-19 cases and deaths but not by as much as in the population with comorbidities. The Epic study and others have found that the association between diabetes and hypertension and COVID-19 is especially pronounced. Among adults, ages 19 to 64, 29.5% of African Americans hospitalized for COVID-19 had diabetes and hypertension compared with 15.7% of the whites hospitalized for disease, according to the Epic data. In the population, ages 65 and older, 36.7% of African Americans hospitalized for COVID-19 had diabetes and hypertension, compared to 22.5% of whites.

Limited access to healthcare of any kind - and perhaps especially to high-quality care - increases the chances that those chronic diseases are poorly managed, and that increases the COVID-19 mortality rate, notes Renee P. Bullock-Palmer, M.D., director of noninvasive cardiac imaging and director of the Women’s Heart Center, Deborah Heart and Lung Center, in New Jersey. Many factors play into healthcare access, especially insurance coverage. Although the uninsured rate among African Americans decreased because of Medicaid expansion and the ACA exchange plans, blacks were still 1.5 times more likely to be uninsured than whites during the 2010-2018 time period, according to the Kaiser Family Foundation (KFF).

The foundation’s numbers suggest that the rate of African Americans covered by health insurance is slipping. Even if they have insurance coverage through an employer, workers in low-paying jobs may be enrolled in less-than-stellar plans. “Limited insurance may impact a worker’s access to a large network of healthcare providers to tend to their healthcare needs,” says  Bullock-Palmer. Work schedules or jobs without paid time off can be obstacles to visiting a doctor. The Sutter researchers said their previous research showed that African Americans are more likely to seek care later in the course of a disease and in acute-care settings, and that same pattern may explain the higher COVID-19 hospitalization rate among African Americans.

 Ph.D., M.P.H., a medical sociologist and health disparities researcher at the University of California, Riverside, has seen COVID-19 healthcare resources being disproportionately distributed to wealthier and predominantly white neighborhoods, making it difficult for many African Americans to access testing and treatment. When African Americans do access care, healthcare professionals tend to take them less seriously, research has shown. 


	Since mid-March, social distancing (and wearing face masks) have been the main public health tactics for preventing the transmission of SARS-CoV-2, the virus that causes COVID-19. But for many African Americans, the tactics are difficult to put into practice. They have jobs in essential businesses that put them on the front lines, notes Bullock-Palmer, so they can’t work from the relative safety of a home office. 

Over the past several years, healthcare providers and payers have turned their attention to the social determinants of health (SDOH) - the influence that housing, nutrition, personal safety and other factors have on people’s health outside of traditional medical care. The toll that COVID-19 is taking on African Americans is more evidence of the power of SDOH, and the need to address them to affect health outcomes, say many observers - although with COVID-19 the list of SDOH has grown longer. Public transportation is an example: “[It] poses an increased risk of contracting the virus, because many of these essential workers have to take buses or subways to work,” says Bullock-Palmer.

A large body of research shows that poor housing is associated with chronic diseases ranging from conditions ranging from heart disease to obesity to anxiety. And crowded living conditions could be a factor in  COVID-19 transmission. 

“It is much harder to self-isolate to protect other family members and neighbors in close proximity,” observes Christopher Chen, M.D., CEO of ChenMed, a privately held company in Miami that operates about 70 primary care practices around the country. 


	Hospitals in low-income neighborhoods were overwhelmed and experienced the most severe equipment shortages as the COVID-19 outbreak grew larger, says Amida Care’s Wirth. Community health centers had to adapt quickly. Telemedicine visits were up but overall visits were down, leading to declines in revenue throughout the healthcare sector. 

Many hospitals and federally qualified health centers depend on volume for revenue in fee-for-service arrangements. “With social distancing orders in place, there has been a marked decrease in volume at healthcare organizations,” Chen says. “Combined with increases in coronavirus infections, a decreased patient volume has resulted in significant revenue loss. Many healthcare facilities have resorted to salary cuts, hiring
	freezes and unpaid furloughs. Federal dollars have helped but have not nearly made up the difference.”


	Many states are bracing for large budget shortfalls because of the economic downturn from COVID-19. Meanwhile, because of job losses, the number of Americans eligible for Medicaid coverage is expected to increase. A KFF projection estimated that 17 million more Americans may be enrolled in Medicaid next year.  Chen describes COVID-19 as a “perfect storm to create a spike in demand for Medicaid coverage.” 

It is difficult to know exactly how COVID-19 will affect the insurance coverage among African Americans. African Americans make up just over 13.4% of the country’s population; in 2018, roughly 20% of nonelderly Americans covered by Medicaid were African Americans, according to KFF figures. But many of the states that haven’t expanded Medicaid have large African American populations, including Mississippi (36%), Georgia (29%), and Alabama (26%).  A surge in unemployment among African Americans in those states may not increase Medicaid enrollment as much as the number of those who are uninsured.  


	COVID-19 has brought to light several issues regarding African Americans’ health and healthcare. “First and foremost, COVID-19 has revealed the impact of centuries of inequality and racism that make up the African American experience as well as that of other people of color in the United States,” says Melva Thompson-Robinson, Dr.PH., a professor at the University of Nevada, Las Vegas, School of Public Health, and executive director of the university’s Center for Health Disparities Research. “Too often, lay people like to think that health disparities result from people’s lifestyle choices. But COVID-19 has highlighted differences in access to care, impact of unemployment, and lack of health insurance, as well as the impact of high housing density on health.”

Wirth says  that COVID-19 is just the latest public health crisis to lay bare the statistics showing the country’s health disparities and the gap between white Americans and communities of color. “While the data is shocking, it is not surprising that the coronavirus is impacting people of color. Such health disparities have existed for years and are now in plain view for the world to see.” 

Polonijo says many steps could be taken that could also help lessen statistical inequalities in other preventable diseases. “Policies such as living wage and paid sick leave could help individuals to meet their basic needs and prevent disease transmission in the workplace,” she said. “Affordable healthcare and equitable allocation of healthcare resources could help alleviate barriers to healthcare access. Enhanced provider training in cultural competency and social determinants of health could help to improve patient/provider encounters for African Americans, as well as other marginalized populations.” 

“I hope that people will continue to ask the questions to understand why the differences exist,” says Thompson-Robinson, “and then will join together to fight the good fight to address the disparities.” 

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.

Health and healthcare inequities are the most likely explanation for the disproportionate effect.

Deadly and Revealing: The Toll That COVID-19 Has Taken on the African American Community

As the number of COVID-19 cases climbed and the death toll rose, healthcare organizations of all kinds and sizes took steps to combat the disease, keep their workers and the people they serve safe while also maintaining their operations, often in some scaled-down way. Managed Healthcare Executive® interviewed six healthcare executives about how they and their organizations have responded to the outbreak.

Steve A. N. Goldstein, MD, PhD, vice chancellor of health affairs and a professor at the University of California, Irvine (UCI)

Since the first day the virus was recognized, UCI Health researchers and medical experts began working closely with other hospitals and healthcare providers both regionally and across the nation to share best practices while staying current with the latest information, treatments, and tools.

UCI Health infectious disease experts are also assist- ing with statewide and national efforts to develop policy, track the outbreak, and contain the spread of COVID-19. We are in regular contact with the CDC, the California Department of Public Health, and the Orange County Health Care Agency.
	Teams of UCI researchers are partnering with other UC medical centers on studying the antiviral drug remdesivir as a COVID-19 therapeutic drug. Backed by the NIH, the clinical trial is considered the first that has possible efficacy and should be ready for patients soon. Other UCI groups are testing cutting edge methods to test who is infected and who was infected previously to tailor treatments and to understand how the disease is spread and how it can be controlled.

Genevieve D. Caruncho-Simpson,MPA, president and chief operating officer, Texas Health Aetna, Dallas

The health plan’s front door is the Anytime-MD app, where members can receive free or low-cost care support from a local emergency room physician. As a text-first app, without any time limit, it supports swift and ongoing communication.

Our doctors are working closely with local hospitals, other providers, and a mobile urgent care provider, DispatchHealth, to make sure members’ questions are being answered via the app in a timely manner. The app allows our doctors to perform ongoing clinical support and virtual triaging of suspected COVID-19 cases. Members can have prescriptions delivered straight to their door through a CVS free delivery program. Free emotional well-being support is also available, as heightened anxiety can occur during this time.

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We are also waiving cost sharing related to COVID-19 testing, providing care package to people who have been hospitalized because of COVID-19, waiving limits on early refills, and through some of our care management programs reaching out proactively to patients who are most at risk for COVID-19.

Romilla Batra, MD, MBA, chief medical officer, SCAN Health Plan, Long Beach, California

Seniors are at the heart of SCAN, and we’re working diligently to keep them safe, healthy, and independent during this pandemic. In addition to implementing all state-of-emergency measures related to access to care, we’re identifying high-risk members-those on ventilators and oxygen-and reaching out to ensure they have everything they need.

We recently checked in on a member who lives alone and learned that she was running out of food. To ensure that she could continue to shelter in place, we arranged for meal deliveries starting the next day.

SCAN’s free telehealth benefit is key, and we’re encouraging members to use it now more than ever for urgent or after-hours care. Because routine care visits are now being discouraged due to the coronavirus, all doctors are being encouraged to do telehealth-type calls with patients to ensure they’re staying on track with treatment plans. This is especially important for patients with chronic conditions or others who need monitoring. It’s better for our members’ regular doctors to triage symptoms because they know their patients’ health histories and status.

On a community level, we are prioritizing emergency funding for nonprofits to help them respond to the growing demand for their services, specifically those that address loneliness. We have also adapted many of our community services from in-person to telephonic, including clinical programs for seniors and caregivers and many of our volunteer efforts. We understand that self-isolating can cause loneliness and, in some cases, depression. That is why we’re making it a priority to keep seniors engaged and supported.

Vincent Nelson, MD, vice president, medical affairs and interim chief medical officer, Blue Cross Blue Shield Association (BCBS), Chicago, Illinois

We have made a systemwide commitment to ensure that members can swiftly and smoothly access the right care in the right setting during the COVID-19 outbreak. This includes covering, with no cost share to the member, the appropriate medically necessary diagnostic testing for COVID-19 when it is not covered as part of the public health service response. Any care for a COVID-19 diagnosis will be covered consistently with the standard provisions of a member’s health benefits. Additionally, BCBS companies will waive prior authorization for medically necessary services and diagnostics related to COVID-19 to ensure patients receive the right care when and where they need it.

Charles A. Peterson II, MD, president and chairman of the board of directors, Proliance Surgeons, Seattle, Washington

Because excellent medical and surgical care involves close physician-patient interaction, on March 15 we chose to postpone all elective (i.e., non-urgent and non-emergent) surgeries in our ambulatory surgery centers and temporarily suspend similar patient care at all of our facilities during the coronavirus outbreak in the region. The postponement will be effective from March 17 until at least March 27 when we will reevaluate the crisis’s status.

As a specialty-care surgical organization, we are offering our surgical teams to provide urgent and emergent surgical care in our centers as a critical backup to Puget Sound area hospitals. We are offering assistance in delivering acute care for patients with fractures, trauma, or urgent surgical care in seven different surgical specialties. Giving hospitals the option of providing surgical services at our centers ensures that our hospital colleagues can focus on COVID-19 patients. This maintains social distancing standards, preserves personal protective equipment, and lowers the potential for COVID-19 exposures.

Shea Harrelson, PA-C, and Scotty Branch, co-founders, Vikor Scientific, Charleston, South Carolina

As a pioneer in antibiotic stewardship and advanced diagnostics, Vikor Scientific’s first plan of action was to dedicate 2,000 square feet of space in its new Charleston headquarters specifically for COVID-19 testing. This will enable us to do high-volume testing and serve as many patients as possible. Vikor Scientific is currently validating COVID-19 testing. Once approved, Vikor Scientific will be able to test 1,500 patients daily with a 24-hour turnaround-time from sample arrival. Vikor purchased new equipment and supplies as well as hired additional staff to execute our plan. We have also dedicated our Pennsylvania location for COVID-19 testing, which will enable us to perform twice as many tests.

Managed Healthcare Executive® interviewed six healthcare executives about how they and their organizations have responded to the outbreak.

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, heart disease, cancer, diabetes, obesity, and Alzheimer’s disease are currently among the most expensive health conditions in the United States. The price tags are staggering.
	
	The CDC says chronic disease-along with mental health conditions-accounts for 90% of the $3.5 trillion in annual U.S. health care expenditures. But calculating health care spending by condition or disease is complex with a welter to consider.

Several years ago, researchers at the Institute for Health Metrics and Evaluation at the University of Washington set out to estimate spending by disease category. They wound up using 183 different sources of data to tally up the spending on 155 different conditions. When the federal Bureau of Economic Analysis (BEA) calculated disease-based healthcare spending for 2016, the largest category, at $334 billion, was a catchall of “ill-defined” conditions that includes colds, allergies, and preventive services. To further complicate matters, cost gets defined in different ways. Sometimes it is used to refer to direct costs on medical services. Other times, the indirect costs of lost income get factored in-and not just those for the people affected by the disease, but also those who take care of them.

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Yet, despite this Rubik’s cube of variability, caveats, and judgment calls, there is fairly broad agreement on which health conditions are going to be most costly for the American healthcare system over the next decade.


	Virtually, every list puts cardiovascular disease (CVD) at the top of the cost charts. The American Heart Association’s 2019 heart and stroke update put the 

 of CVD at $351 billion-most of it ($214 billion) in direct costs.

In the BEA’s disease-specific tallies, CVD at $249.4 billion, was second only to the ill-defined conditions categories as the costliest disease. Sheer prevalence is a major factor in the expenditures for CVD. The AHA says nearly half of American adults have CVD. New guidelines that expanded the definition of high blood pressure are one of the reasons such a large proportion of American population are categorized this way.

CVD is not only expensive and common, it’s often deadly. In fact, heart disease remains the leading cause of death in this country despite real progress in prevention and treatment. In 2017, heart disease caused 

 American deaths, or 23% of the total for that year.

In the next 10 years, many of these numbers are expected to increase because risk factors for CVD are still major problems, notes 

, MD, MPH, the chief medical officer for L.A. Care Health Plan, a Medicaid managed care health plan in Los Angeles that is the nation’s largest publicly operated health plan.

True, smoking rates have been on the decline for decades and are at all-time lows. But in 2017, an estimated 14% of Americans adults were “every day” or “someday” cigarette smokers. That translates into a 34 million smokers, a sizable number by almost any standard. Obesity rates have been climbing for decades; almost 4 out of every 10 American adults are obese. Of course, obesity is a risk factor for type 2 diabetes, and the 

 says that more than 9% of Americans have diabetes, an all-time high. Seidman points out that adults with diabetes are two to four times more likely to die from heart disease than those without diabetes.

Treating CVD involves a wide range of costly medical services: diagnostic tests, ambulance trips, hospital stays, angioplasty, bypass surgery, to name just few. The pharmaceutical armamentarium for CVD is large, and generics have lowered the expense of some classes of medications-statins are the prime example. Yet, the American Heart Association 

 that one in 8 in eight heart patients skips their medication because of price and affordability.

“Until we can bring the costs of medications down, noncompliance will continue,” Seidman says. “People who don’t adhere to their medication regimen will get sicker, raising costs even more.”

Cancer is common-1.8 million new cases will be diagnosed this year, according to the American Cancer Society. It’s also lethal-roughly 600,000 Americans will die from cancer this year, although the mortality rate has been dropping. The 2.2% decrease from 2016 to 2017 was the largest decline in a single year, according to the cancer society. The flip side to declining mortality is an increasing number of cancer survivors. If projections made by NCI researchers almost 10 years ago are holding true, there are now more than 18 million cancer survivors in the U.S.

Given these numbers, some of the cost estimates for cancer are surprisingly low. The BEA put the cancer price tag at $135.8 billion, and the Institute for Health Metrics and Evaluation arrived at a figure of $115.4 billion, which is considerably less than its estimate for CVD ($231.1 billion) and mental and substance use disorders ($187.8 billion).

Howver, those estimates were made before the current surge in expensive cancer treatments and, more particularly, the advent of the costly immunotherapies. Prices of more than $100,000 a year are no longer the least bit surprising.

“While new therapies are more effective and individualized based on a patient’s individual genomic makeup or the cancer’s genomic makeup, overall cancer treatment is becoming much more costly on a per patient basis,” says 

, MD, MMM, FACP, chief physician executive CareMount Medical, a multispecialty medical group in a health system in Chappaqua, N.Y.

Expensive treatment in combination with benefit design that leaves patients and their families exposed to high costs made “financial toxicity” a major issue in oncology. Scott Ramsey, MD, PhD, director of the Hutchinson Institute of Cancer Outcomes Research in Seattle, has conducted the leading studies on financial toxicity. Ramsey and his colleagues have shown that cancer patients are 2.6 times more likely to declare bankruptcy than people without cancer. Drug companies and healthcare systems have a variety of ways of insulating patients from sky-high prices, but it isn’t complete protection by any means.

Apart from price and the vast array of prevention and treatment choices, demographic and other trends are likely to push cancer incidence and prevalence up in the coming decade.
	The march of the baby boomers into their seventh and eighth decades will be a factor.

“The number of cancer diagnoses will likely continue to climb as the population continues to age,” says Seidman, pointing out that in 10 years’ time all the boomers will be older than 65.

Alcohol consumption is a risk factor for several types of cancer, according to Seidman. Several years ago, results reported in 

 that were based on an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions showed that more Americans are drinking alcohol, and more are drinking to a harmful level. Obesity is another potent, ascendant risk factor. Much of the evidence comes from observational studies, so it has some iffiness to it, but the associations are strong for liver, kidney, endometrial, and several other cancers.

“With obesity continuing to rise in the United States, the costs of treating such cancers will also rise,” he says.

In its ranking of 2013 spending on 155 health conditions, the Institute for Health Metrics and Evaluation ranked diabetes as the most expensive one at an estimated $101.4 billion-most (57.6%) of the money paying for pharmaceuticals.

A 2018 report from the Milken Institute on the cost of chronic disease identified diabetes as the second only to CVD in direct costs ($189.6 billion vs. $294.3 billion CVD). Prevalence, as usual, is one of the reasons for the expenditure. The American Diabetes Association says there 30.3 million Americans with diabetes, a figure that includes 7.2 million people who haven’t been diagnosed. A 

 in 2017 projected that number of Americans will increase in the 2020s and reach 54.9 million by 2030.

Latinos are a growing proportion of the American population, and diabetes is more prevalent among Latinos than other groups; for example, Latino adults are 1.7 times more likely than non-Latino white adults to be diagnosed with diabetes.

“Diabetes will continue to be an expensive medical condition 10 years from now because of the many complications that occur, most of which are related to sedentary lifestyles and unhealthy diets,” says Richard Dal Col, MD, MPH, chief medical officer, of EmblemHealth, a nonprofit health insurer in New York. “The longer someone has diabetes that is not well-controlled, the higher their likelihood of complications over time-including renal and cardiac failure.”

The dramatic jump in the price of insulin is also having a significant impact on the cost of diabetes care. A congressional 

 stated insulin costs jumped nearly 300% from 2002 to 2013.

“Government leaders at all levels have been pressuring drug companies to do something about these rising costs, but the companies argue that the high price is due to new insulin formulations that continue to be produced,” Seidman says.

Furthermore, the new formulations blunt competition from some lower-priced generics.

Whether obesity is a risk factor or its own health condition might be debated. But there’s no question that more Americans are getting heavy. The latest CDC estimate is that 39.8% of Americans adults are obese, with obesity defined as a BMI of 30 or greater. The estimate for children is 18%, although obesity in children is defined by percentile, not a set BMI.

“Not only are obesity rates increasing but obesity is starting earlier in life, adding more years of exposure to risk,” says Morel. “Combined with increasingly sedentary lifestyles, the prevalence of costly complications from obesity will continue to drive higher costs of care.”

The Milken Institute report says chronic diseases caused by obesity and being overweight (a BMI of 25 to 29.9) accounted for almost half (47.1%) of the total cost of chronic disease in 2016, including $480.7 billion in direct cots and $1.24 trillion in indirect costs.

Migration patterns within the U.S. may further deepen the country’s obesity epidemic.

“There is regional variation in obesity, in part due to differences in the built environment and local lifestyles,” says Adam C. Powell, PhD, president of Payer+Provider Syndicate, a healthcare consulting firm in Boston.

Many states with lower obesity rates, such as California, New Jersey, and New York, where 25%-30% of the population is obese, are experiencing net outflows of people, according to Powell. Meanwhile, states with higher obesity rates, such as Florida, Tennessee, and Texas, where 30%-35% of the population is obese, are experiencing net inflows of people.

The Milken Institute estimated the direct cost of Alzheimer’s disease at $185.9 billion. The Institute for Health Metrics and Evaluation figure of $36.7 billion is far less. In fact, according to the institute’s ranking, Alzheimer’s is the 21st most costly health condition. The discrepancy in the estimates is a reminder that these are just estimates made with differing assumptions and criteria.

More than 5 million Americans are currently living with Alzheimer’s. As the older population increases, that number is expected to increase dramatically. By 2050, nearly 14 million Americans are expected to have Alzheimer’s, according to the Alzheimer’s Association’s 2019 facts and figures report.

Matthew Baumgart, the senior director of government affairs for the Alzheimer’s Association, said the combination of aging baby boomers and improving outcomes for other diseases that affect older people mean that the incidence of Alzheimer’s is likely to increase-and with that, the cost.

Billions have been invested in Alzheimer’s research and drug development, but the results have fallen far short, so high drug costs are not much of a factor-yet-in the cost of Alzheimer’s. But people often live with Alzheimer’s for many years and that can mean years of expensive care in a nursing home or elsewhere.

Often, the cost figures for Alzheimer’s don’t include the billions of dollars of uncompensated care that more than 16 million family members and friends provide, notes the disease advocacy group. In 2018, unpaid care for people with Alzheimer’s and other dementias totaled more than 18 billion hours, at an estimated economic value of $234 billion, according to the Alzheimer’s Association.

“Unless disease-modifying treatments are discovered, these costs will continue to skyrocket over the next decade and beyond,” says Baumgart.

The extended family, including children and grandchildren, used to be the primary caregivers for people with Alzheimer’s and other kinds of age-related dementia, says Morel.

“But with higher rates of dual-income families, more individuals with Alzheimer’s and dementia are moving to long-term care facilities or rely on home health, adding a huge expense going forward,” he adds.

In addition, folks will see an increased number of hospital admissions for the frail and elderly with cognitive issues, but many will be unable to go directly home after discharge,” he says. “Instead they will require additional care in subacute or rehabilitation facilities, further adding to care costs.”

There is fairly broad agreement that conditions like cancer, diabetes, and more will be the most costly for the American healthcare system over the next decade.

Author | Karen Appold

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