Health care money trail could lead to policy solutions to control spending while improving patient outcomes

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Following the health care money trail can lead to new ideas on how to handle medical conditions for patients around the country.

For example, large-scale treatment of ischemic heart disease could serve as a template for improving care for Type 2 diabetes and musculoskeletal disorders that now cost the nation more than $100 billion a year.

The findings of the study “Tracking U.S. Health Care Spending by Health Condition and County,” also can be used to identify areas where patients lack access to health care — and maybe areas where it is being overused, said Corresponding Author Joseph L. Dieleman, PhD.

The study, published Feb. 14 in JAMA, logged how much money patients and insurers spent on health care from 2010 to 2019. It has financial and medical details that could inform health care policy, especially as the new administration of President Donald J. Trump seeks to Make America Healthy Again.

Dielemen is associate professor of health metric sciences at the Institute for Health Metrics and Evaluation at the University of Washington. He discussed the findings with Medical Economics.

Joseph Dieleman, PhD
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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: What are some policy solutions, and what are some maybe redirecting some of the spending to prevention and management instead of treatment?

Joseph L. Dieleman, PhD: Ischemic heart disease is this really fantastic story where we see reductions in disease prevalence, based on the numbers that we use. If you're looking at age-standardized numbers, you see essentially cheaper treatment and better management, so essentially less utilization of things like emergency department care and inpatient care. When you put those all together, we see either flat or even lowering spending. It's a great template for where we want to be going with some of the other health conditions, especially something like diabetes, which through interventions can be managed or prevented in some cases, much earlier on, and essentially avoid some of the downstream, really expensive costs that happen oftentimes in emergency departments or ambulatory care services. I do think ischemic heart disease offers this kind of template, or this kind of vision of what we'd want to see. With new technologies and new pharmaceuticals in particular, there's a lot of opportunities for diabetes right now. We see it coming in at such a high level of $144 billion. More spending on pharmaceuticals might lead to outcomes that are improved. It might actually initially lead to increases in spending, but over time, again, using ischemic heart disease as the model, we would expect that if spending went up initially to fund some of those pharmaceuticals, eventually, we would see reductions in spending as the disease is managed, or, in many cases, prevented.

Medical Economics: How do you anticipate that these findings might add to the national conversation under the administration of President Donald Trump and the efforts to Make America Healthy Again?

Joseph L. Dieleman, PhD: The message that I would want both the administration to receive, and throughout different agencies, and for that matter, state governments as well, is this topic of variation in spending and access to services. For me, that's just one of these really important takeaways from this study, that we have spending levels that are so different, and it can be partly explained by prices and partly explained by age and disease prevalence, but mostly it's about utilization, which right away suggests that some places are maybe having problems with access and not getting the services that they need, especially the downstream services related to prevention and management of key diseases. That would be the takeaway that I would want the administration to hear from this study, is that this variation suggests that there's problems with access in some places, and that those places are not getting the services that they could use or need. The flip side of the variation is that there's also excess use, or that there might be excess use, and our study kind of points to that. The variation could be explained by underutilization in some places and or could be explained by over utilization. I tend to think that both of those things are true, that the huge variation is partially about low access in some places, and maybe overutilization in other places. In some ways, the study beckons more research and to say, well, can we use these data combined with health outcomes data to ask the question, is there an optimal? Are there some exemplars, some counties that we really see are doing it right? And that's kind of the direction that we want to go with this research. But even without that research conducted yet, I think a takeaway can be, let's use this data to highlight where there seems to be, less resources being used, and ask the question critically, is that, is that right, or is there under use? Is there a need that's not being addressed? And the same goes for the other side of the coin, looking at places with the most resources, saying is, are all these resources necessary, or is there some over-utilization in an economy and spending more?

Medical Economics: What about the study did I not ask about that you would like our readers to know?

Joseph L. Dieleman, PhD: One thing that we didn't touch on is, some of the other health conditions that have spending that is growing tremendously fast. If you look at the national level, some of the diseases that have growth that's really high, I mentioned Type 2 diabetes and other musculoskeletal disorders. But some of the other ones are anxiety disorders, substance use disorders, opioid use disorders. There's a bunch that stand out that are growing tremendously fast, and again, through access to health care early on, can be either prevented or managed at a lower cost. This is tremendously important, both mental health and substance use, behavioral health conditions in general. There's a lot of opportunities to curb some of that growth and spending by intervening and providing services early. And I think those conditions which are growing so quickly, while they're not the very highest spenders right now, offer perspective on where we want to be focusing some attention as well to slow some of that growth and make sure people are getting the services they need when they need them, to prevent some of the highest spending.