Financial toll of health conditions: hundreds of billions of dollars

© JAMA

Any number of health conditions spur patients to seek medical help from physicians and other clinicians every day.

That interaction hopefully leads to a good outcome for the patient. It also begins a financial transaction that adds to a huge part of the American economy.

“Tracking U.S. Health Care Spending by Health Condition and County,” published Feb. 14 in JAMA, logged how much money patients and insurers spent on health care from 2010 to 2019. Researchers also analyzed what patients and insurers are spending the money on — the ailments and conditions that doctors train to treat in the first place.

Joseph L. Dieleman, PhD, is corresponding author and associate professor of health metric sciences at the Institute for Health Metrics and Evaluation at the University of Washington. He spoke with Medical Economics about a decade’s worth of dollars and cents, and the diseases and illnesses, that he and his colleagues examined.

Joseph Dieleman, PhD
_{© Institute for Health Metrics and Evaluation, University of Washington}

There is an accompanying original investigation, “Drivers of Variation in Health Care Spending Across U.S. Counties,” and an editorial, “Tracking U.S. Health Care Spending: Learning From Variation.” JAMA Health Forum published “Understanding Geographic Variation in Health Care Spending,” an editorial that cites the research.

This transcript has been edited for length and clarity.

Medical Economics: The study examines health care spending, but it also looks at patient health conditions. What was surprising among those?

Joseph L. Dieleman, PhD: Part of the study really focuses at the cross-county information about different county level estimates. And then the other part is really disaggregating by health condition, looking at how much is spent on each one of the major health conditions. In this study, we take all health care spending and break it up into 148 different health conditions. What we found at the national level, and this is reflected in some counties, but certainly not all, that the highest spending was on a set of four diseases that stand out, and I've been thinking a lot about. All of those have about $100 billion of spending each year.

The first is Type 2 diabetes, which actually has $144 billion of spending in 2019, and I think that's interesting, along with the second case, which is other musculoskeletal disorders, which is an unfortunate name for a complex set of musculoskeletal diseases and disorders that includes joint disorders and osteoporosis, among other things. What diabetes and other musculoskeletal disorders have in common is that the spending is growing tremendously fast. If you go back a decade, those aren't the top two, but because they're growing faster than the spending growth in other health conditions, they've kind of pushed themselves to the very top. I mentioned, diabetes has over $144 billion of spending in 2019, this category of other musculoskeletal disorders has over $109 billion of spending. And again, both have really high growth rates.

One of the things that makes other musculoskeletal disorders stand out is that, unlike most diseases, they’re really concentrated with over 50% of the spending on the working age adult population. So unlike a lot of health conditions that are especially acute for the 65-plus age group, we see that other musculoskeletal disorders is really throughout the lifespan, especially in the kind of middle, working age, adult years. So that's quite distinct.

The third category, one that surprises people often, is a category that we call oral disorders, and that's essentially all dental care that is not preventive. We have a different category that is your standard, once-every-six-months cleaning or so. But in this oral disorders category, we include orthodontia, cavities, any sort of minor or serious dental surgery that's taking place, all falls into this oral disorders group. And we see that is about $93 billion of spending in 2019 so almost $100 billion. So really the third largest and a huge category. The thing that stands out really about oral disorders is that over 50% almost 60% of the spending, comes out-of-pocket. We know that dental insurance and the dental coverage, even with that insurance, varies dramatically across the U.S., and it's much less common for people to have dental insurance. As a consequence, we see that a lot of dental and dental services, especially this category of oral disorders, is spending that's out-of-pocket. Of course, that's a really big deal because it impacts the household’s bottom line, the budget in the moment. It leads to people asking the question, do I absolutely need these services? Can I put them off? We know that's an impact from out-of-pocket spending on health. The other is that, of course, it just leads to medical debt and people having to sacrifice other things to pay for their medical care. Oral disorders is a really big, important category that I think oftentimes dental care is overlooked when a study isn't really comprehensive and capturing all the types of care.

The last one that I'll mention as far as health conditions that we've been looking a lot at is ischemic heart disease. And ischemic heart disease came in at about $81 billion in 2019. I think the really interesting and important thing about ischemic heart disease is, to contrast it with Type 2 diabetes and other musculoskeletal disorders, it's growing really slow. If we went back a decade, ischemic heart disease would be the number one spending category. But what we've seen is that between better management and prevention and lower cost treatments, spending on ischemic heart disease is really quite flat. And even if you adjust for age and disease prevalence, then we actually see it's a reduction in spending, which is really remarkable, and not something we see with a lot of health conditions, especially something that's such a large category and important disease as ischemic heart disease.

Medical Economics: How can primary care physicians integrate these findings into their clinical decision making?

Joseph L. Dieleman, PhD: That's a great question, and I think a hard one to answer because our study, while it's so granular in some ways, it remains a very macro study. It's looking at these big disease categories or the county as a whole. It's built on claims information that is individual and personal. But the results themselves are much bigger than that.

Maybe as an aside that I think is important, in this study, we don't pull out primary care as its own type of care that we focus on. In future studies, we really aspire to do that. In fact, it's one of our highest priorities, to take this ambulatory care bucket, which in our analysis, is 42% of all health care spending — so it's this really large bucket, and it's growing very quickly — and break it apart into some of its constituents. So be able to say something specific about primary care, say something specific about outpatient surgeries and specialty care, say something specific about urgent care or other pieces that make up this very large category of ambulatory care. So that's something in the works, and something that we hope, even in this calendar year, that we're able to speak more on.

But back to your question of, how do primary care physicians maybe use this in their day to day clinical work? I tend to think, from a policy perspective, it's especially important to think about access. The study, to me, has lots of really important takeaways, but the one that resonates the most is that we have this huge amount of variation. In some places, access is fundamentally lower than it is in others. So in the primary care world, I think access, of course, is a really huge deal. And ensuring from a policy perspective, and to do whatever is possible to increase access in hard-to-reach areas and to increase reliance on primary care is a huge priority. This study reflects that by just saying, look, there's this amazing variation in ambulatory care, much of that is also reflected in primary care across the counties, throughout all the years that we're looking at in this study.

Medical Economics: The study did note the growth of spending on emergency care. Can you talk about that, and if money would be better spent on preventing and managing conditions as a way to alleviate some of that emergency care?

Joseph L. Dieleman, PhD: What we found, first to be clear, is that emergency department spending is growing tremendously fast. In our way of looking at the numbers, emergency department care only includes the treat and release population. So emergency department care, if you're talking to emergency care physician, for example, what they do is much more than just the treat and release cases, because anyone that's admitted also has some time in the ED often. So what we're capturing when we say emergency department care is really not the full bucket of ED spending and ED services. But like you said, it is growing tremendously fast. As far as the takeaway for that is, thinking specifically about what services could be taken care of outside of the ED that are currently being treated in the ED, again, that comes to primary care. I think in many ways, both disease prevention and management are at home in the primary care space and our study, with the increases in ED spending, highlight that there's a real role and need, especially when you look across all of the counties, for access to those services.