The 2014 Atlanta Summit - - The Economic Burden of Chronic Disease: Preventing the Preventable

Ross Duvall (Milken Institute) – Data Analysis & Trends

• Study Scope: Updated the 2007 "Unhealthy America" report, analyzing seven chronic diseases (cancer, diabetes, heart disease, hypertension, stroke, COPD, mental illness) against a 20-year baseline forecast.
• Heart Disease Progress: Prevalence rates fell below the baseline forecast, driven by smoking rates dropping further than assumed and the widespread use of generic statins.
• Diabetes & Hypertension: Actual prevalence was substantially above the baseline forecast, largely due to the identification and treatment of previously undiagnosed type 2 diabetes cases.
• Stroke Outcomes: Stroke prevalence was significantly higher than original baseline assumptions.
• Cost Trends: Medical inflation and treatment costs per patient have increased at a slower rate than baseline projections for all conditions except heart disease.
• Cost Drivers: Overall economic burden remains slightly above the baseline, driven by increased prevalence, though medical inflation has hit its lowest rate in four decades.
• Future Strategy: Duvall advocates focusing on behavioral incentives ("carrots or sticks") to address the root causes, noting that while medical inflation is controlled, behavioral changes remain the critical next step.

Steve Bird (Safeway & Bird & Company) – Private Sector Interventions

• Cost Reduction Achievement: As a self-insured employer of 185,000 people, Safeway reduced its projected $1.8 billion health care bill to $850 million by lowering costs by $150 million and halting the industry-typical growth rate.
• The 80-20 Rule: Bird identified that 74% of all health care costs are concentrated in four diseases: cardiovascular disease, cancer, diabetes, and obesity.
• Biometric Standards: Safeway implemented a program where 85% of employees opted into a plan with biometric standards; employees with a BMI ≥35 paid elevated premiums but received full refunds for reductions of 10% by year-end.
• Smoking Cessation: The program achieved a 35% smoking quit rate, verified via cotton swab tests rather than self-reporting.
• Ecosystem Approach: Bird estimates that biometric wellness accounts for only 15% of potential savings; 70% of savings in his new company come from unproven ecosystem solutions like "promotoras" (community health agents) and peer support groups.
• Scalability Claim: Bird asserts that if 30 companies replicated the Safeway model, the nation's health care expenses could be cut by 50%, and he offered a free pilot to the U.S. Senate which was rejected in favor of a 5-year competitive RFP process.
• Insurance Critique: Bird argues the private sector fails to implement these solutions widely because self-insured firms are merely claims processors, and benefits managers lack the authority to innovate compared to CEOs.

David Heber (UCLA) – Nutrition & Physiology Insights

• Obesity Transmission: Visual analysis of Framingham data suggests obesity spreads through social networks, with "nodes" of heavy individuals gaining weight over time, rather than affecting the population uniformly.
• BMI Limitations: Body Mass Index is misleading, particularly for Asian and Indian populations; an MRI study showed individuals with identical waist circumferences could have an eight-fold difference in internal abdominal fat.
• Visceral Fat Impact: Internal abdominal body fat acts as an inflammatory organ driving metabolic syndrome; diet alone often fails to target this fat, necessitating a combination of exercise and nutrition.
• Caloric Math: Burning off two ounces of potato chips requires 3 miles of running; burning off two colas requires 8 miles of cycling, necessitating 30–45 minutes of daily exercise commitment.
• Muscle Mass & Metabolism: Muscle burns 14 calories per pound (approx. 30 per kg); a 100lb lean woman burns 1,400 calories daily vs. a husband's 2,100 calories, proving "one size does not fit all" for dietary planning.
• Sedentary Risks: Prolonged sitting causes hamstring shortening and muscle cell degradation, leading to chronic issues like knee replacements and back pain independent of obesity.
• Gut Microbiome: Abdominal fat alters gut bacteria (firmicutes/bacteroidetes ratio), increasing susceptibility to viral infections and inflammation; healthy diets can reverse these microbial imbalances.
• Policy Recommendation: Heber urges the CDC to adopt a new nutrition philosophy focused on obesity and inflammation rather than traditional vitamin deficiency models.

Ken Thorpe (Emory University) – Policy & National Strategy

• Medicare Spending Drivers: Since the mid-1980s, 80% of Medicare spending growth is attributed to chronic disease prevalence; 85% of spending is linked to patients with five or more chronic conditions.
• Current Disconnect: Federal debates on Medicare/Medicaid focus on budget cuts (payment rates) rather than health policy, failing to address the clinical reality of multimorbid, overweight patients.
• Three-Point Agenda: Thorpe proposes shifting to a health reform agenda focusing on disease prevention, early detection, and patient engagement/management to reduce hospitalizations.
• Underutilized Interventions: Proven interventions like the Diabetes Prevention Program (DPP) and new FDA-approved weight loss drugs are effective but not covered by fee-for-service Medicare.
• Pilot vs. Scale: Thorpe argues the U.S. is "not one pilot project away from a miracle," urging the transition from small-scale pilots to scaling proven private-sector models (like Safeway's) into federal programs.
• Entitlement Reform: He calls for reframing Medicare reform from a budget exercise to a health strategy that addresses entitlement growth through health improvements rather than provider payment cuts.
• Sense of Urgency: Unlike smoking or HIV/AIDS, which triggered urgency due to mortality, obesity is a morbidity issue requiring a new coalition to generate public urgency.

Consensus & Strategic Barriers

• CBO Scoring Constraints: The Congressional Budget Office's 5-to-10-year scoring window penalizes preventive investments as "cost increases" before savings materialize, effectively blocking public prevention funding.
• Regulatory Hurdles: Organizations attempting outcome-based standards face complex navigation of HIPAA and ADA regulations, limiting the number of firms implementing true biometric outcomes.
• Social Perception: Chronic diseases are a "slow bleed" ($50/week vs. $6,000/year cost perception); speakers argue for "shock and awe" campaigns to visualize long-term costs (e.g., 25,000 amputations from diabetes) to overcome the illusion of immortality.
• Integration Challenge: Healthier behaviors and population health functions are currently orphaned from traditional insurance benefit structures; speakers advocate for monetizing these actions via tax credits or Medicare payment adjustments.
• Implementation Philosophy: Panelists criticized the demand for double-blind, controlled trials for all interventions, citing the Electronic Health Record's successful launch without prior evidence as a counter-model for rapid adoption.