health care gets the least amount of attention and study. so about six or seven years ago i went back and look the at some of the literature what do we know from published data what's driving the growth in health care spending? really, the last, one of the last few pieces i saw was a piece that joe did. i guess it was from '92-93, joe newhouse, looking at the time period between 1940 to 1990. and if you think about it, you know, that was a very different time period than the most recent experience that we've had, the number of uninsured went from 90% to 15%. so clearly the amount of induced spending as our whole system changed over time was roughly related to changes in the structure of insurance and demand and as joe has just talked about innovation. brought medicare, medicaid on and various estimates what that contributed to the growth in health care spending's we had a

whole bunch of really important new innovations that fundamentally change how we treat patients. neonatal intensive care units and treatment of low birth weight babies a treatment for cardiovascular disease and so on. it was a very different time period. what i'm goin' to spend my discussion on is really looking at the time period between the early 1990s and today and i think the point i'll make is even during that time period, the year-to-year changes and what's driving a growth in spending is somewhat different, but i really want to look at some of the long-term drivers here that are more recent. and i've sort of taken, you know, you can deexpose this com different ways. i sorted it's in into buckets. the change in spending, the change in the prevalent of treated disease. looking at the change in spending linked to how much we

spend to treat a case. and obviously their interactions between the two of those. if you look at a long-term kpoernt component here, say late '80s to today, 60% of the growth is linked to rising prevalent of treated disease. we'll go into sort of what accounts for that. some of that is going to be good. i'll argue some of it is going to be bad that we can go in and potentially do something about. so just to give you a sense of some of these, the magnitude of the changes here, and you can go down by medical condition and see the prevalence increases, and for each of these conditions the factors driving the growth, they're somewhat different. soap if you look at the treatment of cholesterol, a-of-mental disorders, those are obviously increase dramatically, much of that is technology related. we have new approaches for treating patients with

cholesterol. we have new medical interventions to treat people with mental disorders that we didn't have 30 and 407 ye years. diabetes, i'll come back in a minute and talk about that. that's almost all an incidence increase. that's not really anything that has to do with increased detection. that's largely just more cases of patients with diabetics. this is a particular problem, as we'll see in the med kairp plam. one of the key drivers in rising medicare, rising in diabetes and other cardiovascular diseases. go down list. there are enormous increases in prevalence of crete e treated d. take a step back and say, what's driving this growth? some of it i mentionedrd things we should be happy about. some are things we shouldn't be happy about. so the first one is, as mentioned, diabetes.

our detection rates of diabetes really haven't changed much in the last 20789 or or 30 years. today, about 22%. from the upper 60s. 10, 15, 20 years ago, but not doing a lot better in detecting diabetes. so the prevalence, treated prevalence numbers received for that are really just incident increases not detection increases. the second one is obviously debatable and controversial but no question over time we change the definition of disease. so we've had a change in clinical thresholds for treating different types of conditions. particularly cardiovascular disease. i think that most ef the studies i've seen that looked at that think that's a good thing. a more aggressive treatment for cardiovascular risk factors has

been declines rates of mortality over the last 20 years. new medical technologies obviously treatment of mental disorders and joe went through that, provide more tools for us to treat patients that we didn't have 30 or 40 years ago. we're living longer. so you're going to see some increases in the disease prevalence linked to longevity, and the changing definitions of disease. so if you look at the definition of just something as simple as diabetes, that's changed a little over time. in terms of the clinical blood sugar levels that kick off at the diagnosis of diabetes versus pre-diabetes. one of the things that's very different in this time period that we're looking at is increases in obesity. if you look at the 1960s, 1970s, 1980s, that whole time period, the share of adults considered obese was about 17%.

really didn't change for about 30 years. so clearly not a contributor over the time period that are joe was looking at to rising health care costs. it was just not changed. you know, it was constant. that's not the case most recently. soap if you look at the long-term trends here, and hopefully we're stabilizing it a little bit, it's doubled since the mid-1980s. and if you look at some of the, you know, calculations that are just linking, or looking at how much of the growth in spending is due solely to obesity holding neckful knowledge constant, treatment constant, depending on the period you want to look at it accounts for 7% to 10% of the rise in spending. cbos did an estimate, they came up with 8%. of all the things we can quantify to joe's point, to the things we can try to quantify, it is a, an important contributor. if you look at medicare

spending, about one thempd -thie growth in medicare spending over the last decade is linked to sort of cardiovascular risk kingses. diabetes, arthritis, hypertension, mental disorders. the thing that's interesting about those particular conditions in the medicare program is that those are conditions that are ambulatory treated with appropriate medication. unless you botch it up somehow, with the exception of kidney disease, you really have nothing to do with in-patient hospitals here prp this is really issues dealing with ambulatory care, primary care, medication management. and the ultimate irony of that is that traditional fee for service medicare is really the only major payer, unless you're home homebound that has no care coordination. just doesn't do it. they'll tell you you have a flob your personalized care plan we

we don't have anything available to engage patients in medicare to help them manage these conditions. we've done some tabulation to kind of try to sort these out in terms of spending increases over time, and as i've mentioned, the share spending increase linked to disease preference versus cost per case does differ over the time period you're looking at. the most recent couple of years, obviously, were in an economic slowdown. so we have slower rates of utilization and eve the last couple of years, spending pr treated case snd and more important rising health care spending, look at the long-term trepds, it really is a disease prevalence that are driving you. but if you try to drill down a little more on this and say look at treatment intensity. meaning, how much are we spending to treat a particular case of diabetes or heart

disease? over time. and how much of this is just due to increases in obesity, again, holding technology constant? as i mentioned, about 7% to 9% is due to obesity "loan. look at the 1997 and 2001, intensy of treatment how we're ingauging and working with patients. ship is due to changes in technology, clipiccal thresholds for treatment, clinical recommendations for how aggressive we should be treating patients. they're all bottled up into the same bucket here. but treatment intense tip is a major component of this as well. if you look at both obesity and treatment intensity, inn where anywhere from 20% to 30% of the growth is linked to both combined. so what are some of the challenges here? that we face.

we know that any given year that obese adults spend about 40% more in health care. and depending on, there's a whole range of different estimates how much is in the base of spending linked to obesity, and i think the last piece assa was something around 20%, 21%, is dupe to obesity in the base of healthcare spending. obviously as a productivity component we spend time focusing on the health care piece, but if you look at the total cost of chronic health care conditions, for every buck we spend on the medical side we're losing about $4 in productivity. so there's a bigger component to this that's really important. let me go back to my medicare challenge here. the medicare program, if you look at age 65, look at lifetime health care expenditures starting at age 65. and if you compare the lyfetime spending of an obese adult

versus a normal weighted adult, and there's a couple good models that have done these estimates. anywhere from 20% to 40% more spending over the course of the lifetime piece of an adult at age 65 on medicare. so the point is, this is a very different story than smoking. smoking's a mortality discussion. this is a morbidity discussion. that there's not really that were yump differ regs linked to obe obesity. seems to me, think about medicare, two things that are important. one is to find ways to change the incoming health profile of people coming into the program, because there are long-term potential savings associated with having a healthier population coming in at age 65. and let's just go back to the care coordination piece. and i'm sure melanie will talk about this and they're doing a

great job of trying to build more care coordination and do lpgts eligibles here. if you think about evidence base, care coordination interventions i think programs like medicare are enormous. over the next decade, medicare is going to spend roughly $500 become to $600 billion on readmissions that we could potentially prevent. that basic question, why don't we build something into the program, actually be effective in do this. and we actually have interventions that are effective. so we have a program that eric colmal developed -- coleman developed some time ago. comes up with very similar results. that should be a major component

built in for fee for service medicare that woman accompany this broader wellness package that we built in. ip think there's opportunities here but we've got to focus on i think two of the problems that we can actually do something about. one is preventing and averting disease in the first place, and love to have the discussion about some of those opportunities through things like the diabetes prevention program i've written on, and, second, to build into programs like medicare evidence-based components and care coordination that we basically have decades worth of randomized trials that show that they work. things like transitional care. medication therapy management. health code chain. having an integrated care coordination model into the primary care practice. so we mow the elements that are factored. i think we just need to find ways to integrate them and build them into medicare. so with that, i'll keep this

short and i really look foerpd to the discussion. >> great. well, thanks to both 6 you. we now have time for clarifying questions that people want to the ask questions specifically of ken or joe to draw them out on points they made. we don't want to get into a lot of deep analysis of what they said at this point, or debate, but 1yu69 again, clarifying questioned. if do you have a question, introduce your name by name and affiliation and be sure to switch on your mike. if not, let me ask, the moderatorses to ask one to you, joe. if i look at your slide labeled high cost of advancing technology, the one you label x-ray machine, et cetera. >> right. >> and i look at current technology, i see two items mentioned there. surpgry robot, and treated stent. both of which recent stupdies have shown do not materially

produce better outcomes for patients. and, in fact, with respect to the treated stents i think johnson & johnson's unit stopped making them, because they were so clearly not just ineffective lut problematic for patients. that underscores that we have a lot of technology out there that i either does not produce better outcomes but yet kwofts a lot more, or, in fact, can be harmful. medicine tells us half of all the medical interventions we engage in, there's no evidence that they work at all. so i was curious as to why you didn't put even more emphasis on some aspects of technology assessment as being potentially of more actionable solution? >> well, i think since everybody believes that, i wanted to make the counterpoint and disagree with it. the point what we're going to

focus on is in fact the treated stent and less the scourgery robots. since that's a big marketing tool for hospitals and people want to believe that somehow putting a machine between the surgeon and their body is -- is necessarily an improvement. they wale would like an improvement there because they think they could be seriously harm the or killed. but, you know, the fact is that we do have a tendency especially on stents, for example, smaller things, we do have a tendency to look at those. for one reason, it's easier to examine the affect of a stent because it is a purpose. it doesn't have maumt poultiple purposes. there's some skill in it but it's a somewhat momp more singular product that is more amenable to testing, and that, i

think, is maybe the point i'm trying to make that we have a tendency to examine the things that are easy to examine, and not the things that are really hard to figure out. and -- and the hardest things to figure out are the things that are standard practice. so, yeah. there's some hope for technology assessment. there's -- my view, there isn't much hope's in going from good technology assessment to sound medical policy, but there could be plenty of hope going from good technology assessment to good professional standards. >> and, ken, a quick question for you. you have used the phrase treated prevalence here a lot, suggesting that you're distinguishes between just prevalence and treated prevalence, obviously. we actually treat people. can you desegregate those two pieces? i mean, how much of -- for

example, it's potentially possible we're giving statins to a lot of people for high cholesterol and a lot of debate whether that is even the correct set of interventions. so how much of this is treatment versus treated prevalence. >> now i'm confused. [ laughter ] geez. it's not even happy hour. >> are you sensitive about these heart issues? [ laughter ] >> well, the phrase for me, treatment, treated prevalence is the distinguish of the fact we really are only engaginging a fraction of patients that have different conditions. so to go back to my diabetes example, 28% of people that live with diabetes have not been diagnosed and don't have a medical intervention.

at some point hopefully they will, but at any point in time, they're not. so that's the distinction. the other part of it is, you know, didn't is an important issue. ip try to distinguish in this, in the discussion that there are components of prevalence that we can intervene and do something about, and we want to. so issues around obesity and lifestyle and diet and exercise and things like diabetes we can reduce the curve on. there are other components of this, where if you go back to my slide and look at the treatment of cholesterol and hypertension, that are a, you know, a medical call that says, you know, if we are more aggressive, at treating those diseases, plus we have the new technologies to do it, that it does proup better value. that we're reducing cardiovascular mortality, improving the quality of life and so on.

i think some of the stuff david and others have done looking at the impact of anti-hypertensives and anti-hypertensives have had are good investments. those are also part of the discussion here is that we have we have changed and made medical decisions and treatment decisions to say we're more aggressive at treating the risk factors. that they do pay off. >> we're building systems of care coordination for seniors. my question to you is, i'm a primary care dock for a third of a century and research as well. all of our discussion is focused on the providers.

what about preference of patients, particularly seen near the end of life population, where our data is showing now they would prefer not to be patients. they would like to be comfortable and stable and safe at home. we have systems to begin to do that. we have a lot of studies now on effectiveness, in other words, is the treatment necessary and valuable, what kind of data do we have on preference where we begin to know whether the treatments are actually wanted or unwanted, which is much less controversial than trying to decide what is necessary. you often can't know what is necessary until after you do it and it hasn't worked. it's not controversial to know that people don't really want this stuff and as it turns out many of them don't.

and to your point of giving people options and decisions about the type of care. how aggressive they want care to be towards the end of their life. i don't want to bring up death panels. but that's a legislate mat discussion that needs to be built into decoding of medicare. how they talk about options. i'm seeing more and more models

come into place. hospice is another important component of that. having the time to have that discussion in a fee for service system is a real problem. it's not built into the coding. it's not meant on the amount of time on important decisions like that. it should be built into how we think about doing care coordination and primary care with patients to give them options and have the options out there available. the incompleteness of the medicare we're going do give you a personalized care plan that says you're overweight and prediabetic. but we don't cover anything to do anything about it.

we've shone in randomized trials, including community bassed randomized trials they generate a 5 to 7% weight loss. that should be an option. if i want to make a difference in terms of changing lifestyle or improving my blood sugar levels, that should be a component of what medicare covers. on both extremes we don't give people a whole lot of options because of the way that medicare cover policy works. >> can you reference several initiatives around the identifyrs of cost drivers. can you speak a little bit to what happens to utilization and outcomes as thee interventions

take place. >> well, yeah, that's a good question. you can look at the prevalence data in terms of how we're treating patients with cardiovascular risk factors. the most important question is what are we getting from it? is it worth it? i think on balance the more aggressive is worth it. we're getting improvements on longevity and improvements on the quality of life. so those are outcomes. things that are good increases. things that we want to make investments in and should be

happy about. we've done on statins and cholesterol and there's a series of prevalence increases that are bad that we should try to do something to reduce our incident increases linked to lifestyle and diet and exercise and smoking and so on, like diabetes. there are different -- there are different issues how we think about them i think are very different. >> let's see, tom miller. is your head up there? we'll come back to mary ellen. tom miller, a.i. we've gotten good and clever coming up with new names to call chronic conditions, got a code, we can find a technology and bill to throw at it. you have a list of the ones that you've had greater treated prevalence. when you do your time series, what have we had any reduction in, in term of treated prevalence? what's gone off the the list? great savings in smallpox. is it an added key to the keyboard?

>> that's a good question. we've broken these into i guess we have 260 that we've looked at, and i'd say most of them are fairly constant. i mean, obviously big ones like heart disease and cancer are getting improvements in. the one that has been the biggest decline which actually adds to, you know, actually adds to a lot of the cost is trauma. the prevalence of trauma cases has gone done fairly substantially. that's a big reduction. but most of these have seen, you know, fairly substantial increases over time. a lot as i mentioned have been obesity related and a lot related to cardiovascular risk factors. i think kind of the interesting thing is, is that if you look the spending growth of the united states, going back to '40s for '50s, not that it's a whole lot difference. it's 2, 2.5 percentage points

above gdp, you're not out of whack internationally either, we have seen differences in what's generating that delta. so if you look at a medicare patient in 1965 versus today, they're very different. i mean the clinical profile's different of the patients. the typical patient, driving in spending medicare today is overweight 70-year-old hypertensive diabetic with bad cholesterol, asthma, back problems, pulmonary disease and is depressed. those are all conditions that really require behavior change engagement, appropriate ambulatory care, nothing that medicare does. >> let me add something, though. this is a pitch for a technology. one of the reasons we have more treated prevalence on nearly

everything is, it's easier to treat. also there's the push for so-called prevention, which means earlier diagnosis, so it's hard to know where all of these fit in. i do think that the march of medical progress is contributed considerably to this trend. >> so mary ella payne and i think dan callahan has a hand up, as well. >> should we be thinking more about targeting hot spots or targeting populations or targeting industries? a lot of what we generally talk about is broad policy changes in medicare and other areas. but certainly the obesity and other risk factors seem to be located in certain parts of the u.s., i would argue. should we start to focus on those areas and maybe not have across the board sort of improvements but in order to get