What do we know?

Patients with five or more chronic conditions account for two thirds of the Medicare spend in the US (Figure 1). It has not been possible to find similar data from other countries, but it seems likely that the picture would be similar in other developed countries. In other words, caring for patients with complex chronic disease is increasingly the main activity and the main cost for health services. As patients have more chronic conditions they are more likely to be admitted to hospital (Figure 2), often unnecessarily and incurring considerable cost. In the UK, a small number of patients, most of them frail elderly individuals with polypathology, accounts for a high proportion of unplanned hospital admissions (Figure 3). These admissions entail a considerable cost.

 Figure 1. Percent of medicare spending per person by number of Chronic Conditions (Average annual expenditure)

Source: Medicare Stantard Analytic File. (9)

Figure 2. Unnecessary hospital admissions related to the number of conditions coexisting in a person

Source: Medicare Standard Analytic File (9)

Figure 3. A small percentage of patients account for many hospital bed days

Source: Analysis of British Household Panel Survey (2001). (10)

Few studies are available on the cost of chronic illnesses for developing countries, and to our knowledge none evaluating costs associated with the management of patients with multiple chronic diseases (11).

 In the United States care for people with chronic disease represents 70% of healthcare expenditure (12), but the associated loss of productivity due to disability, unscheduled sick leave, a decrease in effectiveness in the workplace, an increase in occupational accidents or negative impacts on work quality and customer care represent an even higher financial cost to countries than those related to healthcare services.

Figure 4. Distribution of Medicare Cover and Expenditure in Different Sectors of the Population
 

Source: Medicaid (13)

Dependence associated with chronic diseases

In 2006 the WHO estimated that there were 650 million people with disabilities worldwide, representing 10% of the population (14). In the US it has been shown that disabled people account for most of the Medicaid budget despite representing a minority of cases (Figure 4) (13).

Most polypathologies are associated with a high level of dependence, a concept which goes beyond disability in as much as it implies a person's need for support in order to perform ordinary everyday activities (as a result of physical, psychological, intellectual or sensory limitations). It has been estimated that people who are dependent as a result of chronic diseases represent about 2.5% of the total population (15).

A recent report by the Organization for Economic Co-operation and Development (OECD) highlights important levels of disparity among countries in terms of the amount of resources available to support dependent individuals, and a dearth of data on the economic scale of the services provided by family caregivers (16). The latter places a serious limitation on estimates of the costs associated with chronic diseases as it is widely recognized that most of the cost of caring for dependent people is assumed by family members (17). As the proportion of dependent people increases and fertility rates decrease, it is reasonable to expect a shift in this burden and its related costs from family members to the traditional system of health and social services (18, 19).

Influence of lifestyles and disease risk factors on healthcare costs

The prevalence of chronic diseases is closely related to unhealthy lifestyle habits (see Chapter 3). In the United States, the estimated cost represented by these habits in 2000 was (20):

- Smoking: 75.5 billion dollars in medical costs and 92 billion dollars associated with productivity losses (21).

- Obesity and excess weight (2002): 132 billion dollars (92 billion in direct costs and 40 billion in indirect costs) (22).

- Poor nutrition: 33 billion dollars derived from medical costs and 9 billion dollars of lost productivity as a result of cancer, cerebrovascular accidents and diabetes which can be attributed to bad nutrition (www.cdc.gov/nccdphp).

One study found that these risk factors increase expenditure by 25% (23). Altogether, smoking, alcoholism, obesity and hypertension consume 1.5% of GDP in China and 2.1% in India (24). The cost increases with the number of health risk factors (Figure 5).

Figure 5. Estimated 2008 US Healthcare Cost per person by extent of risk factors (figures in US dollars)

Source: PricewaterhouseCoopers 2008 - World Economic Forum - Working Towards Wellness Business Rationale (25)

Healthcare costs are higher in people who are sedentary without being overweight than in obese people who are physically active (26). In Spain, two out of three children of school age and 38% of young people appear to be sedentary in their free time (27).

Interventions over lifestyles could have a big impact on expenditure on chronic diseases, essentially through weight reduction, improved nutrition, regular exercise, giving up smoking and early diagnosis and treatment (Chapter 3). Unfortunately, most countries around the world, and even organizations such as the WHO, allocate insufficient resources to health promotion and disease prevention. The latter, for instance, invested less than 8% of its budget in activities related to these two areas, and to mental health, substance abuse and the management of chronic diseases (28). The early targeting of risk factors, whether through pharmacological or behavioral interventions, has many potentially positive effects (Table 1).

Table 1. Cost per Group of Countries per Quality-adjusted Life year of Cholesterol and Hypertension Level Control Measures.

Source: Murray et al. (2003) (29) Centers for Disease Control and Prevention. (2004) (30).