Monthly Healthcare Insights: Heart disease, healthcare costs

Monthly Healthcare Insights: Heart disease, healthcare costs

American Heart Association projects increase in cardiovascular disease and cost

The American Heart Association (AHA) has used the National Health and Nutrition Examination (NHANES) survey data set to estimate the likely burden of cardiovascular disease in the next quarter-century. The headline is that increasing obesity and high blood pressure will lead to an increase in the rate of cardiovascular disease, and overall cardiovascular disease costs will triple over this period.

First the good news. The AHA projections suggest that the rate of adult behavior that increases risk of heart disease will generally improve over this time period. Fewer will smoke, fewer will have a poor diet and more will exercise. Fewer will have high cholesterol due to more effective treatment. However, fewer will sleep well, and better sleep has been associated with a lower risk of cardiovascular disease.

But there’s more bad news. More than half of adults had hypertension as of 2020, and this study projects that rate to exceed 61% by 2050. Almost one in six adults (16.3%) has diabetes; that number will increase to more than one in four (26.8%). Some of the increase in cardiovascular disease is due to the aging of our population, but much is due to increased risk factors including obesity, hypertension and diabetes.

A separate set of researchers used these projections to estimate the cost of cardiovascular disease. The researchers used inflation-adjusted dollars, so this increase is due to increasing disease and utilization, not simply due to prices increasing each year.

Much of the increased medical costs are in those over age 65 and is borne by Medicare. In the commercial population, cardiovascular disease causes substantial economic productivity loss as well as increased medical costs.

Behavioral risk factors for premature heart disease are generally declining, but not enough to blunt the increasing risk from obesity and an aging population. Higher rates of cardiovascular disease will lead to higher medical costs and more lost productivity.

Implications for employers:

  • Better treatment of obesity can help. But the current high price of GLP-1 medications means that their use will be limited. Employers can lower cost sharing on other anti-obesity medications.
  • The increase in hypertension is especially concerning, and effective treatment of hypertension is inexpensive. Employers can ask their carriers to report regularly on hypertension control, which is a standard HEDIS reporting measure.
  • Employers can make first and second-line anti-hypertensives at the lowest cost share, to decrease any cost barriers to these effective medications. This can help address the problem that among the commercially insured with known cardiovascular disease, only 55% had adequate control in 2022. Employers can raise awareness of the risks of hypertension, and combine movement and exercise wellbeing programs with their anti-hypertensive efforts.
  • Stress management can improve hypertension and heart health risks. Employers can highlight stress management and resiliency programs available to their members through EAP or wellbeing programs.

National health insurance expenditures projected to grow

The Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS) published its projections of medical costs through 2023 in Health Affairs. They estimate that medical costs will rise to $7.7 trillion by 2023, 19.7% of gross domestic product. This increase is driven by the expectation that medical inflation will continue to outpace overall inflation and economic growth. Some of this increase is due to our aging population, but more is due to faster growth in health care prices.

The Office of the Actuary estimated that the annual cost per member for private health insurance would increase from $6,838 in 2023 to $10,576 in2032. Private health insurance is mostly people on employer-sponsored health insurance, although the category also includes individual health insurance purchased on the marketplaces. The researchers projected that employer-sponsored health insurance would gain 2.5 million beneficiaries when the marketplace subsidies from the Inflation Reduction Act expire in 2026, although retirement of the youngest baby boomers means that 4.3 million fewer people will be on employer-sponsored health insurance in 2032 compared to 2024.

Implications for employers:

  • The challenge of making health care affordable for employees and for the business is likely to increase over the coming years as health care inflation is projected to outpace general inflation.
  • The decrease in those covered by employer-sponsored health insurance in the coming years is due to demographic changes likely to cause labor shortages in many industries, which could lead to higher wages and pressure for more generous benefits.

U.S. lags other countries in maternity care

The Commonwealth Fund released its report on maternity care in the U.S. and 13 other developed countries. The maternal mortality numbers are no surprise, and exceptionally bad for Black U.S. moms. The researchers report that almost two-thirds (65%) of maternal deaths were during the postpartum period, up to a year after delivery. They note that the U.S. is different from these other countries in a few ways.

  1. The U.S. has the lowest supply of midwives and obstetricians. Further, in many better-performing countries midwives outnumber obstetricians, but in the U.S., midwives make up only a third of providers of delivery care.
  2. Maternity care is often unavailable close to home. Nearly seven million women in the U.S. live in counties with no obstetrical providers and no places to give birth.
  3. The U.S. has no mandated parental leave.
  4. Out-of-pocket costs for maternity care are high in the U.S. Nearly eight million women of reproductive age are uninsured. Women with employer-sponsored health insurance with out-of-pocket costs had average cost-sharing of over $4,500 in 2015, part of a large gender gap in out-of-pocket costs.  

Although the Commonwealth Fund doesn’t emphasize this point, almost a quarter of postpartum deaths in the U.S. are attributed in part to issues around mental health.

Implications for employers:

  • Employers can offer an insurance plan with affordable premiums so that those having children can avoid high deductibles if they can’t afford them.
  • Employers can offer robust mental health benefits and insist that their carriers have networks with adequate access.
  • Employers can offer parental leave to decrease the financial and emotional stress on new parents.
  • Other employer-sponsored programs, including virtual advocacy programs and digital monitoring programs for high blood pressure, gestational diabetes and premature labor can be helpful.
  • Similarly, 24/7 professional assessment for anxiety and depression can help direct those needing mental health services.

Obesity epidemic is not because we are eating more and exercising less

Many think that Americans are getting more obese because they are eating more and exercising less. But there’s substantial evidence to the contrary.

I was recently on a panel in Cleveland with Robert Lustig, a pediatric endocrinologist and emeritus UCSF professor. He’s the author of several books, including Obesity Before Birth Maternal and Prenatal Influences on the Offspring (2010) and Fat Chance: Beating the Odds against Sugar, Processed Food, Obesity, and Disease (2013).

He showed data on caloric intake — which has been steady over the last two decades, while obesity levels have soared.

He also noted that Americans’ exercise levels have increased. The portion of Americans who exercise enough to meet guidelines has grown in the last quarter-century. Guidelines recommend either 150-300 minutes of moderate exercise or 75-150 minutes of vigorous exercise each week.

So, what is the cause of increasing obesity in the U.S. and around the globe?

Clearly, there are some foods that have a higher “glycemic index,” which is why carbohydrates, especially those that are highly processed, cause more insulin release and more weight gain than eating protein or fat. This explains why very low-carbohydrate diets (like ketogenic diets) are effective in promoting weight loss.

Lustig focuses on ultra-processed foods and obesogens. Foods that have been heavily processed have high glycemic indexes, which stimulate insulin secretion and fat storage. We eat highly processed sugar-coated breakfast cereals instead of whole-grain oatmeal, for instance.

Obesogens are a large set of synthetic chemicals that cause obesity even without excessive caloric intake. These include plastics and pesticides. They can be found in food packaging and personal care products. This category includes “forever chemicals” that have been in nonstick cookware and stain-resistant fabrics. Many are “endocrine disruptors,” which change human metabolism and can lead to weight gain. Endocrine disruptor exposure before birth and in early childhood is associated with later obesity. Clinical studies have shown that those with higher blood levels of PFAS (perfluorinated alkylate substance, a forever chemical) regain more weight after stopping a diet than those with lower blood levels of this chemical.

Implications for employers:

  • Obesity has multiple causes, and childhood weight and even prenatal exposures can predispose people to adult obesity.
  • The obesogen hypothesis reminds us that obesity can’t be solved by exhorting people with high BMIs to “just eat less.”
  • Employers that offer on-site cafeterias can offer food that isn’t highly processed and doesn’t contain harmful additives.
  • Employers can watch for regulatory action to decrease worker exposure to obesogens.

BMI is a flawed measure with few practical alternatives

Body Mass Index (BMI), which is used to assess whether people are underweight, normal weight, overweight, or obese, wasn’t designed to support clinical decision making. This measure is only modestly correlated with metabolic obesity. However, there aren’t great practical alternatives.

BMI was initially designed by a Belgian mathematician seeking to assess obesity in the overall population, not to judge the health of individuals. The measure doesn’t include waist size, and abdominal obesity is at higher risk than obesity around the hips. It isn’t adjusted for age. Athletes with large muscle mass are misidentified as obese, and Asian people can be obese with adverse metabolic health even with BMIs in the “normal” range. Those with normal BMIs but more belly fat measured by waist circumference have increased mortality. The American Medical Association recommended de-emphasizing BMI last year.

The ideal measure of obesity should be highly correlated with whether a person has fat in and around their organs. This is the type of fat which dramatically increases the risk of diabetes and cardiovascular, kidney and liver disease.

There are alternatives to BMI, but each has its disadvantages. None can be assessed remotely, and many require highly trained examiners or expensive equipment:

  • Waist circumference assesses abdominal fat, a risk factor for cardiovascular disease and early death. Interobserver variation is high, but this is a widely used metric.
  • Waist hip ratio is recommended by the World Health Organization to assess obesity. Again, interobserver variation is high.
  • Skinfold thickness uses a caliper to estimate body fat composition. This metric requires a skilled examiner, and there are differences among caliper manufacturers.
  • Bioelectrical impedance sends a weak electrical current through the body to estimate percentage body fat. This requires specialized equipment and training.
  • DEXA scan (dual-energy X-ray absorptiometry) uses low-dose radiation to measure body composition. There’s a small amount of radiation exposure, and this requires specialized equipment and training.
  • Hydrostatic weighing submerges the body in fluid to calculate body density. This and air displacement are only done in research laboratories.
  • Air displacement plethysmography is like fluid submersion and estimates body density and fat percentage.
  • 3D body scanners use lasers and cameras to create a 3-D model of the body. This is an emerging technology that isn’t widely available.

Implications for employers:

  • Body mass index is likely here to stay as a proxy for obesity. It’s simple and inexpensive to calculate and requires little measurement skill or training and no specialized equipment.
  • Employers should be aware that BMI is by no means the “last word” on whether an individual is at higher risk for cardiometabolic complications.
    • Some with substantial abdominal fat and large waist circumferences might benefit from anti-obesity therapy even if their BMI is normal.
    • Others with substantial muscle mass can be incorrectly identified by BMI as obese, and weight loss wouldn’t improve their metabolic health.
  • Restricting GLP-1 prescriptions to those with a higher BMI than 30 (or 27 with a metabolic comorbidity) would mean that a higher portion of those treated would be likely to be metabolically unhealthy and therefore gain the most benefit from these expensive medications. However, employers using a different cutoff for drug eligibility would lose substantial rebates associated with these medications.

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