Who pays the bill and who makes the profit in treating chronic disease?

Lack of financial incentives means prevention is often ignored

“A courtyard common to all will be swept by none” goes a Chinese proverb. Sadly, this ancient saying remains true in the modern American medical system. At the start of the third millennium of Western culture and progress, the suffering of medical illness arguably may be higher than in the centuries past. Until the last 50 years, illness—often combined with poverty—was a greater shortener of lives. But death, compared with today, came more quickly.

In practice, an internist sees the local viewpoint of national statistics: 90 million Americans alive with chronic disease who spend more than 60% of the country's health care budget.¹ Of the 20 or so patients that many physicians see each day, one, maybe two, might not have a chronic disease. Almost every one of these patients has needs far beyond what a doctor can provide. And much of the reason is inferred from two questions: “Who pays the bill?” and “Who makes the profit?”

At a policy level, the “epidemic” of chronic illness is as much a philosophical debate as it is a medical problem. If people live longer, they get illnesses of aging—dementia, loss of vision and hearing, organ failure, and cancers. In addition, chronic illness today may not have even been illness a few years ago. Mild hyperglycemia is now diabetes. The definition of hypercholesterolemia depends on at least 25% of Americans being “sufferers.”

In clinical practice, philosophy is put aside in favor of what we all hope is the current best empirical evidence—that newer definitions of diabetes or elevated lipids are important in identifying people who will someday develop complications. So much of the doctor's day is spent informing patients that they have joined the ranks of the sufferers, even if they don't yet feel the suffering.

But despite the philosophy and the evolving medical evidence, nearly every doctor, at some point, feels like Alice in Wonderland when dealing with chronic diseases. Not only do the definitions change from year to year, the causes are ignored and the treatments can be trivial to the patient's well being.

Most chronic illness is a social problem. The table lists a few of the most common chronic diseases. Cardiovascular disease, cancers, chronic lung disease, and diabetes alone are responsible for about 75% of American deaths. But are these diseases solely the problem of doctor and patient? What should be the role of a doctor? Instead of prescribing nitrates and beta blockers, it may be more productive to help set up community weight-loss and activity-promoting groups. When we open our prescription pads, some of us are haunted by the question, “Could I—should I—be doing something else about this?” Too often physicians can feel they are shifting single grains of sand along the beach during a hurricane.

Table 1.

Most common chronic diseases in the United States

Condition	Prevalence (%)	Annual costs*
Atherosclerotic diseases	25	$274 billion
Diabetes mellitus	6	$98 billion
Oral diseases	86 by age 17	$50 billion
Alzheimer's disease	1.5	$152 billion
Chronic obstructive lung disease	6	$25 billion
Epilepsy	1	$14 billion
Osteoporosis	4	$15 billion
From the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA

^*Costs are direct and indirect and are estimates from 1993 to 1995

Except for the patient and the general community, we all do well by maintaining the status quo. Community leaders are not deposed because of their pro-health positions that would require more vigorous public health measures, and doubtless more taxes. Business firms need not spend money and energy on smoking and lifestyle modification plans for their employees, since most of the suffering will come after retirement. Hospitals and other health care institutions thrive on illness. Health plans, especially managed care plans, could plan community-wide programs to prevent chronic disease. But because of the number of plans and the frequency that customers change plans, the hopes of long-term savings from prevention strategies seem to get lost. (So now, managed care plans focus hard on a handful of measures that are used to rank the plans in a marketplace, not to prevent human suffering.)

And we doctors and our noble profession: If it pays, we do. If not, then... well, maybe. Most of our payers reward us for meeting the prevention targets on which they are ranked—annual eye exams for persons with diabetes, beta blockers for patients who have had myocardial infarction, immunizations for children. But we perform less well when the reimbursement is not direct or is even absent. Monitoring and treating a patient with an elevated cholesterol concentration occurs less often than monitoring glycemic control.² One can guess which is favored by payers, while the evidence might suggest we practice otherwise.³

Those who claim that health care is not a market might step back and take a look at the issue of chronic diseases from the community's view. At that level, for example, the cost of preventing one dental cavity through fluoridation would be $3, while the cost of the dental repair would be $55.¹ For each of us in the medical care industry, the questions become “Whose $3 is spent?” and “Who gets to take home the $55?”

According to the National Center for Health Statistics, almost 20% of Americans over 45 years of age are hearing impaired, but how often do we formally assess hearing? The Center's surveys find that only about 40% of patients with diabetes have ever received formal education about controlling their diseases. In our own medical group, an informal financial analysis showed that a diabetes education program would likely be “financially negative.” In chronic disease, the common good too frequently falls victim to our individual goods.