1 00:00:00,160 --> 00:00:02,080 Welcome everyone to a special edition of the 2 00:00:02,080 --> 00:00:05,040 Becker's Healthcare podcast series. Today, we'll be diving 3 00:00:05,040 --> 00:00:08,320 into a conversation with Sierra Garvin, the senior 4 00:00:08,320 --> 00:00:11,460 associate director of Above Brand Marketing at Behringer 5 00:00:11,519 --> 00:00:12,019 Ingelheim, 6 00:00:12,515 --> 00:00:14,995 and Manny Leonard, senior director of drug use 7 00:00:14,995 --> 00:00:18,435 policy and formulary management at Cleveland Clinic as 8 00:00:18,435 --> 00:00:21,255 featured on Behringer Ingelheim's In Focus podcast. 9 00:00:21,635 --> 00:00:23,494 We hope you enjoy this special episode. 10 00:00:29,309 --> 00:00:31,550 Hello, and welcome to series three of the 11 00:00:31,550 --> 00:00:34,210 InFocus podcast brought to you by Boehringer Ingelheim. 12 00:00:34,750 --> 00:00:36,590 If you haven't already listened to the first 13 00:00:36,590 --> 00:00:39,409 two series on population health management and transitions 14 00:00:39,469 --> 00:00:41,254 of care, make sure to check them out 15 00:00:41,254 --> 00:00:43,814 at strategiesforqualitycare.com. 16 00:00:43,814 --> 00:00:46,054 Today, you're listening to the first of four 17 00:00:46,054 --> 00:00:49,094 episodes, which focuses on strategies for reducing the 18 00:00:49,094 --> 00:00:51,655 total cost of care, a growing concern for 19 00:00:51,655 --> 00:00:53,320 health care organizations today. 20 00:00:53,859 --> 00:00:56,820 I'm Sierra Garvin, senior associate director of Above 21 00:00:56,820 --> 00:00:58,659 Brand Marketing, and I'll be your host for 22 00:00:58,659 --> 00:00:59,399 this series. 23 00:01:00,340 --> 00:01:02,820 It's widely recognized that the high cost of 24 00:01:02,820 --> 00:01:04,599 health care in The US is unsustainable 25 00:01:05,060 --> 00:01:06,920 and disrupts economic stability 26 00:01:07,454 --> 00:01:08,674 with negative consequences 27 00:01:09,054 --> 00:01:11,634 for our patients, payers, health systems, 28 00:01:11,935 --> 00:01:13,474 industries, and society, 29 00:01:13,935 --> 00:01:16,575 even causing some patients to forego needed health 30 00:01:16,575 --> 00:01:17,075 care. 31 00:01:17,614 --> 00:01:19,454 To reduce the total cost of care, it's 32 00:01:19,454 --> 00:01:21,854 important to understand the drivers of health care 33 00:01:21,854 --> 00:01:22,354 expenditures 34 00:01:23,000 --> 00:01:25,739 and to adopt innovations that reduce costs 35 00:01:26,040 --> 00:01:28,060 without reducing care quality. 36 00:01:28,840 --> 00:01:31,159 As we dive into the discussion of cost 37 00:01:31,159 --> 00:01:33,719 and strategies in this series, we'll be joined 38 00:01:33,719 --> 00:01:36,295 by four subject matter experts who will share 39 00:01:36,295 --> 00:01:39,415 information about the causes and impact of high 40 00:01:39,415 --> 00:01:41,814 health care costs and the ways to reduce 41 00:01:41,814 --> 00:01:42,314 them. 42 00:01:42,854 --> 00:01:45,354 We'll also hear about real world approaches 43 00:01:45,655 --> 00:01:47,415 that can help reduce the total cost of 44 00:01:47,415 --> 00:01:47,915 care. 45 00:01:48,920 --> 00:01:51,959 These subject matter experts are Mandy Leonard, senior 46 00:01:51,959 --> 00:01:55,260 director of drug use policy and formulary management 47 00:01:55,400 --> 00:01:56,540 at Cleveland Clinic, 48 00:01:57,159 --> 00:02:00,540 doctor Nihar Desai, an associate professor of medicine 49 00:02:00,600 --> 00:02:02,780 and vice chief of the section of cardiovascular 50 00:02:03,159 --> 00:02:05,974 medicine at Yale University School of Medicine, 51 00:02:06,594 --> 00:02:07,814 doctor Andrew Freeman, 52 00:02:08,194 --> 00:02:10,854 director of clinical cardiology and cardiovascular 53 00:02:11,235 --> 00:02:14,514 prevention and wellness at National Jewish Health, and 54 00:02:14,514 --> 00:02:16,134 Kim Newlin, a cardiovascular 55 00:02:16,594 --> 00:02:20,330 nurse practitioner and clinical performance improvement consultant at 56 00:02:20,330 --> 00:02:21,150 Sutter Health. 57 00:02:22,009 --> 00:02:24,650 For this first episode, we'll talk with expert 58 00:02:24,650 --> 00:02:27,530 Mandy Leonard to explore the systemic and disease 59 00:02:27,530 --> 00:02:30,509 related drivers behind high health care costs. 60 00:02:31,215 --> 00:02:33,055 Welcome to the series, Mandy, and thank you 61 00:02:33,055 --> 00:02:34,034 for joining us. 62 00:02:34,495 --> 00:02:36,514 Hi, Sierra. Thanks for having me. 63 00:02:37,135 --> 00:02:40,175 Mandy, with your background and experience managing drug 64 00:02:40,175 --> 00:02:42,094 related costs for twenty five years at the 65 00:02:42,094 --> 00:02:44,655 Cleveland Clinic, could you start by providing us 66 00:02:44,655 --> 00:02:46,754 with an overview of health care spending? 67 00:02:47,509 --> 00:02:48,009 Certainly. 68 00:02:48,629 --> 00:02:50,789 To begin with, The US spends more on 69 00:02:50,789 --> 00:02:52,969 health care than any other nation. 70 00:02:53,349 --> 00:02:56,229 For example, health care spending accounted for nearly 71 00:02:56,229 --> 00:02:57,129 18% 72 00:02:57,189 --> 00:02:59,769 of our GDP in 2023, 73 00:03:00,055 --> 00:03:03,115 and spending is expected to grow almost 6% 74 00:03:03,335 --> 00:03:04,375 from 2023 75 00:03:04,375 --> 00:03:05,675 to 2032. 76 00:03:06,294 --> 00:03:09,014 The federal government is responsible for nearly one 77 00:03:09,014 --> 00:03:10,635 third of health care expenditures. 78 00:03:11,335 --> 00:03:12,715 And what's most unfortunate 79 00:03:13,094 --> 00:03:15,034 is that despite our larger expenditures, 80 00:03:15,849 --> 00:03:18,409 The US ranks behind other countries in key 81 00:03:18,409 --> 00:03:19,229 health metrics, 82 00:03:19,530 --> 00:03:20,669 such as life expectancy, 83 00:03:21,449 --> 00:03:22,510 obesity rates, 84 00:03:22,889 --> 00:03:25,790 infant mortality, and hospital admissions for diabetes. 85 00:03:27,050 --> 00:03:29,884 That's really surprising that despite the large expenditures, 86 00:03:30,104 --> 00:03:32,344 The US ranks behind other countries in key 87 00:03:32,344 --> 00:03:33,165 health metrics. 88 00:03:33,865 --> 00:03:36,264 So what's driving this significant increase in the 89 00:03:36,264 --> 00:03:37,405 cost of health care? 90 00:03:38,025 --> 00:03:40,185 Well, some of the biggest drivers are the 91 00:03:40,185 --> 00:03:41,805 increasing age of the population, 92 00:03:42,719 --> 00:03:45,919 high hospital readmission rates, and patients who are 93 00:03:45,919 --> 00:03:47,699 high utilizers of health care. 94 00:03:48,159 --> 00:03:50,879 For example, the portion of the population age 95 00:03:50,879 --> 00:03:52,659 65 and older is increasing, 96 00:03:53,199 --> 00:03:55,985 and projections suggest they'll account for more than 97 00:03:55,985 --> 00:03:59,044 twenty percent of the population in 2032. 98 00:03:59,504 --> 00:04:00,965 And in terms of high utilization, 99 00:04:01,745 --> 00:04:04,645 just 5% of The US population is responsible 100 00:04:05,104 --> 00:04:07,685 for nearly half of all health care spending. 101 00:04:08,400 --> 00:04:10,980 Older adults and those with serious chronic illnesses 102 00:04:11,439 --> 00:04:13,199 are some of the biggest users of health 103 00:04:13,199 --> 00:04:16,080 care, and they require more frequent and costlier 104 00:04:16,080 --> 00:04:16,580 treatments. 105 00:04:17,839 --> 00:04:20,240 I can understand how these factors would contribute 106 00:04:20,240 --> 00:04:22,720 to the increase in cost, especially with chronic 107 00:04:22,720 --> 00:04:23,220 conditions. 108 00:04:24,034 --> 00:04:25,714 Could you share more about the role that 109 00:04:25,714 --> 00:04:27,974 chronic conditions play in driving up costs? 110 00:04:28,754 --> 00:04:29,254 Absolutely. 111 00:04:29,875 --> 00:04:32,115 According to a report for the Centers for 112 00:04:32,115 --> 00:04:33,574 Disease Control and Prevention, 113 00:04:33,954 --> 00:04:36,995 about ninety percent of US healthcare spending involves 114 00:04:36,995 --> 00:04:38,694 chronic and mental health conditions, 115 00:04:39,060 --> 00:04:41,379 and about sixty percent of Americans have at 116 00:04:41,379 --> 00:04:42,759 least one chronic disease. 117 00:04:43,459 --> 00:04:46,419 Additionally, patients with chronic diseases account for the 118 00:04:46,419 --> 00:04:47,879 vast majority of hospitalizations 119 00:04:48,419 --> 00:04:49,560 and filled prescriptions. 120 00:04:50,819 --> 00:04:53,540 Wow. Chronic diseases and mental health conditions seem 121 00:04:53,540 --> 00:04:56,175 to account for an extremely large portion of 122 00:04:56,175 --> 00:04:57,154 health care spending. 123 00:04:57,935 --> 00:05:00,175 Do modifiable risk factors play a role in 124 00:05:00,175 --> 00:05:00,675 this? 125 00:05:01,375 --> 00:05:04,254 They sure do. Modifiable risk factors play a 126 00:05:04,254 --> 00:05:06,115 significant role in chronic diseases. 127 00:05:06,779 --> 00:05:09,180 In one study, some of the modifiable risk 128 00:05:09,180 --> 00:05:11,899 factors that were associated with the highest spending 129 00:05:11,899 --> 00:05:14,000 were high body mass index, 130 00:05:14,460 --> 00:05:16,080 high systolic blood pressure, 131 00:05:16,540 --> 00:05:18,240 high fasting plasma glucose, 132 00:05:19,095 --> 00:05:21,274 dietary risks, and tobacco smoke. 133 00:05:21,814 --> 00:05:23,735 Most of the spending related to these risk 134 00:05:23,735 --> 00:05:26,794 factors was in patients aged 65 and older. 135 00:05:27,254 --> 00:05:28,474 In the same study, 136 00:05:28,774 --> 00:05:31,414 certain chronic conditions were found to have health 137 00:05:31,414 --> 00:05:34,069 care costs that could be attributed to modifiable 138 00:05:34,129 --> 00:05:34,870 risk factors. 139 00:05:35,490 --> 00:05:36,310 These included 140 00:05:36,689 --> 00:05:37,189 musculoskeletal 141 00:05:37,569 --> 00:05:38,069 disorders, 142 00:05:38,610 --> 00:05:40,149 chronic respiratory diseases, 143 00:05:40,689 --> 00:05:41,829 digestive diseases, 144 00:05:42,529 --> 00:05:45,589 mental health and substance use disorders, and neurological 145 00:05:45,810 --> 00:05:46,310 disorders. 146 00:05:47,345 --> 00:05:49,524 Are those the most costly chronic conditions? 147 00:05:50,305 --> 00:05:51,444 That's a great question. 148 00:05:52,144 --> 00:05:55,024 All chronic conditions contribute to high health care 149 00:05:55,024 --> 00:05:55,524 expenditures, 150 00:05:56,144 --> 00:05:56,964 but cardiovascular 151 00:05:57,425 --> 00:05:57,925 diseases, 152 00:05:58,464 --> 00:05:58,964 cancer, 153 00:05:59,660 --> 00:06:00,160 diabetes, 154 00:06:00,540 --> 00:06:03,199 chronic kidney disease, and autoimmune diseases 155 00:06:03,660 --> 00:06:05,759 are among the most common and costly. 156 00:06:06,620 --> 00:06:08,560 Let me present some facts to you. 157 00:06:09,019 --> 00:06:09,519 First, 158 00:06:09,819 --> 00:06:12,699 cardiovascular diseases are the leading cause of death 159 00:06:12,699 --> 00:06:15,314 and cost over $250,000,000,000 160 00:06:15,555 --> 00:06:17,495 annually to treat. And secondly, 161 00:06:17,955 --> 00:06:19,894 more than a hundred and thirty five million 162 00:06:20,035 --> 00:06:22,694 Americans are living with diabetes or prediabetes, 163 00:06:23,634 --> 00:06:28,214 resulting in the astounding annual cost of $413,000,000,000 164 00:06:28,915 --> 00:06:30,535 Those are staggering numbers. 165 00:06:31,089 --> 00:06:33,649 If someone has multiple chronic conditions, does the 166 00:06:33,649 --> 00:06:35,110 impact also multiply? 167 00:06:36,289 --> 00:06:37,110 Most definitely. 168 00:06:37,410 --> 00:06:41,089 Having multiple chronic conditions leads to worsening patient 169 00:06:41,089 --> 00:06:42,870 outcomes and higher costs. 170 00:06:43,555 --> 00:06:46,915 Managing chronic conditions is difficult and costly, and 171 00:06:46,915 --> 00:06:49,634 over fifty five percent of Americans have multiple 172 00:06:49,634 --> 00:06:52,535 chronic conditions or what we'd call MCCs. 173 00:06:53,714 --> 00:06:56,960 These are associated with higher mortality rates, as 174 00:06:56,960 --> 00:06:59,860 well as reduced health related quality of life, 175 00:07:00,240 --> 00:07:02,420 increased health care use, and costs. 176 00:07:03,600 --> 00:07:06,480 It's unfortunate that so many Americans suffer from 177 00:07:06,480 --> 00:07:07,780 multiple chronic conditions. 178 00:07:08,480 --> 00:07:10,480 What are some of these combinations, and why 179 00:07:10,480 --> 00:07:12,100 are they so expensive to treat? 180 00:07:12,904 --> 00:07:15,324 Some of the most common and expensive combinations 181 00:07:15,545 --> 00:07:16,524 include diabetes, 182 00:07:16,985 --> 00:07:20,285 cardiovascular diseases, including heart failure and hypertension, 183 00:07:21,064 --> 00:07:23,805 as well as chronic obstructive pulmonary disease. 184 00:07:24,599 --> 00:07:27,319 The most expensive two way combination is heart 185 00:07:27,319 --> 00:07:28,459 failure and cardiovascular 186 00:07:28,839 --> 00:07:29,339 diseases, 187 00:07:29,879 --> 00:07:33,000 which is associated with annual medical costs of 188 00:07:33,000 --> 00:07:34,519 over $30,000 189 00:07:34,519 --> 00:07:35,180 per patient. 190 00:07:35,959 --> 00:07:37,979 Other costly MCC combinations 191 00:07:38,360 --> 00:07:39,259 include cardiovascular 192 00:07:39,719 --> 00:07:41,154 disease with diabetes, 193 00:07:41,615 --> 00:07:42,914 arthritis, asthma, 194 00:07:43,375 --> 00:07:45,714 or chronic obstructive pulmonary disease. 195 00:07:46,495 --> 00:07:49,854 An additional costly combination includes diabetes with either 196 00:07:49,854 --> 00:07:51,235 depression or anxiety. 197 00:07:52,430 --> 00:07:54,189 The high costs are due in part to 198 00:07:54,189 --> 00:07:54,930 the complexity 199 00:07:55,389 --> 00:07:58,050 of treating multiple conditions simultaneously. 200 00:07:59,069 --> 00:08:01,730 This typically involves prescribing several medications 201 00:08:02,270 --> 00:08:05,949 and following various and sometimes conflicting clinical practice 202 00:08:05,949 --> 00:08:06,449 guidelines, 203 00:08:07,084 --> 00:08:09,805 which can often complicate treatment decisions and lead 204 00:08:09,805 --> 00:08:11,584 to poor long term outcomes. 205 00:08:12,365 --> 00:08:14,524 One potential solution is for the experts to 206 00:08:14,524 --> 00:08:16,625 develop joint clinical guidelines 207 00:08:17,084 --> 00:08:19,504 for some of the most common MCC combinations. 208 00:08:20,845 --> 00:08:22,705 It would be great to see that happen. 209 00:08:23,300 --> 00:08:25,060 Are there any other conditions that have a 210 00:08:25,060 --> 00:08:27,080 high cost burden on health care? 211 00:08:27,699 --> 00:08:31,379 There certainly are. Rare diseases also contribute to 212 00:08:31,379 --> 00:08:32,040 high expenditures. 213 00:08:32,899 --> 00:08:35,220 A rare disease is any disease that affects 214 00:08:35,220 --> 00:08:37,160 fewer than two hundred thousand patients. 215 00:08:37,845 --> 00:08:40,004 While the population that has each of these 216 00:08:40,004 --> 00:08:41,304 diseases is small, 217 00:08:41,764 --> 00:08:44,804 the collective population is estimated at 25 to 218 00:08:44,804 --> 00:08:47,764 30,000,000 since there are up to nearly 10,000 219 00:08:47,764 --> 00:08:48,584 rare diseases. 220 00:08:49,445 --> 00:08:51,460 In In one study, the economic burden of 221 00:08:51,460 --> 00:08:55,159 rare diseases was estimated to be nearly $1,000,000,000,000 222 00:08:55,620 --> 00:08:57,539 And this estimate was only based on the 223 00:08:57,539 --> 00:09:00,580 associated costs of just under 380 224 00:09:00,580 --> 00:09:01,320 rare diseases. 225 00:09:01,860 --> 00:09:03,779 So it doesn't account for all of the 226 00:09:03,779 --> 00:09:04,519 rare diseases. 227 00:09:05,595 --> 00:09:08,394 The economic burden created by the direct cost 228 00:09:08,394 --> 00:09:12,014 for rare diseases is $449,000,000,000 229 00:09:12,394 --> 00:09:15,274 And the indirect cost burden isn't far off 230 00:09:15,274 --> 00:09:18,654 from that at $437,000,000,000 231 00:09:19,409 --> 00:09:21,730 Since a rare disease may increase the chances 232 00:09:21,730 --> 00:09:24,710 of having a severe functional impairment or disability 233 00:09:25,250 --> 00:09:28,070 that can actually prevent patients from gaining work 234 00:09:28,210 --> 00:09:31,649 and staying employed, indirect costs are primarily driven 235 00:09:31,649 --> 00:09:33,990 by productivity and opportunity losses. 236 00:09:35,225 --> 00:09:37,245 That's a tough reality for many. 237 00:09:37,785 --> 00:09:40,105 Are there reasons outside of disease states that 238 00:09:40,105 --> 00:09:42,285 contribute to the rising cost of health care? 239 00:09:43,065 --> 00:09:45,384 Well, that's another great question, Sierra, and the 240 00:09:45,384 --> 00:09:48,504 answer is yes. A significant portion of health 241 00:09:48,504 --> 00:09:49,884 care spending is wasteful, 242 00:09:50,299 --> 00:09:52,379 which is defined as spending that can be 243 00:09:52,379 --> 00:09:52,879 reduced 244 00:09:53,179 --> 00:09:56,459 or eliminated without adversely affecting the quality of 245 00:09:56,459 --> 00:09:57,919 care or health outcomes. 246 00:09:58,939 --> 00:10:01,759 A review article published by JAMA in 2019 247 00:10:02,059 --> 00:10:05,424 found that wasteful spending accounted for about 25% 248 00:10:05,485 --> 00:10:06,865 of all health care expenditures 249 00:10:07,245 --> 00:10:08,144 at that time. 250 00:10:09,004 --> 00:10:11,325 To expand further on wasteful spending, the main 251 00:10:11,325 --> 00:10:14,065 drivers are called out as six different domains. 252 00:10:14,764 --> 00:10:16,945 The first is failure of care delivery. 253 00:10:17,539 --> 00:10:20,919 This includes hospital acquired conditions and adverse events, 254 00:10:21,220 --> 00:10:22,759 clinician related inefficiencies, 255 00:10:23,379 --> 00:10:25,860 and the lack of adoption of preventative care 256 00:10:25,860 --> 00:10:26,360 practices. 257 00:10:27,620 --> 00:10:29,559 Second is failure of care coordination. 258 00:10:30,384 --> 00:10:32,804 This category includes unnecessary admissions, 259 00:10:33,264 --> 00:10:34,404 avoidable complications, 260 00:10:34,865 --> 00:10:35,924 and readmissions. 261 00:10:37,105 --> 00:10:39,824 The third category is overtreatment or low value 262 00:10:39,824 --> 00:10:40,324 care, 263 00:10:40,784 --> 00:10:43,284 which includes low value medication use, 264 00:10:43,670 --> 00:10:45,930 low value screening, testing, or procedures, 265 00:10:46,550 --> 00:10:48,730 and overuse of end of life care. 266 00:10:49,430 --> 00:10:50,970 Fourth is pricing failure. 267 00:10:51,350 --> 00:10:52,649 This includes medication, 268 00:10:53,029 --> 00:10:53,529 laboratory, 269 00:10:53,910 --> 00:10:57,370 outpatient, and payer based health service pricing failures. 270 00:10:58,485 --> 00:11:01,625 Fifth, there's fraud and abuse, including in Medicare. 271 00:11:02,485 --> 00:11:04,745 And lastly, there's administrative complexity. 272 00:11:05,365 --> 00:11:08,745 This final category includes billing and coding waste 273 00:11:08,884 --> 00:11:11,625 and physician time spent reporting on quality measures. 274 00:11:12,690 --> 00:11:15,170 Interventions have been proposed to address this wasteful 275 00:11:15,170 --> 00:11:17,730 spending, and it's been estimated that they would 276 00:11:17,730 --> 00:11:20,210 reduce the total cost of waste by about 277 00:11:20,210 --> 00:11:21,269 25%. 278 00:11:22,210 --> 00:11:24,210 Wow. Clearly, there is a lot to do 279 00:11:24,210 --> 00:11:25,990 to help reduce health care expenditures. 280 00:11:26,745 --> 00:11:28,985 We thank you, Mandy, for joining us today 281 00:11:28,985 --> 00:11:31,785 and providing a comprehensive review of what drives 282 00:11:31,785 --> 00:11:32,524 these costs. 283 00:11:33,144 --> 00:11:35,544 And thanks for having me, Sierra. I truly 284 00:11:35,544 --> 00:11:37,404 enjoyed spending time with you today. 285 00:11:37,785 --> 00:11:40,285 It's been a great discussion. Thank you. 286 00:11:41,429 --> 00:11:43,750 As you've heard from our discussion today, preventing 287 00:11:43,750 --> 00:11:46,009 the total cost of health care from continually 288 00:11:46,230 --> 00:11:48,410 increasing presents a major challenge. 289 00:11:49,110 --> 00:11:51,429 Fortunately, the challenge is being taken up by 290 00:11:51,429 --> 00:11:54,230 organizations that are adopting newer methods that help 291 00:11:54,230 --> 00:11:56,095 reduce costs without impacting 292 00:11:56,475 --> 00:11:57,214 care quality. 293 00:11:58,315 --> 00:12:00,315 With that, we encourage you to join us 294 00:12:00,315 --> 00:12:02,794 for our next episode, where we discuss value 295 00:12:02,794 --> 00:12:05,754 based care and the opportunities this method provides 296 00:12:05,754 --> 00:12:07,934 to reduce overall health care costs. 297 00:12:10,179 --> 00:12:12,899 Together, we can make a meaningful impact on 298 00:12:12,899 --> 00:12:14,199 the future of health care. 299 00:12:14,740 --> 00:12:16,360 Thank you for joining us. 300 00:12:27,284 --> 00:12:29,205 Thank you, Sierra and Mandy for your time 301 00:12:29,205 --> 00:12:31,445 and insights today. And we also wanna thank 302 00:12:31,445 --> 00:12:33,625 our podcast sponsor, Boehringer Ingelheim. 303 00:12:33,982 --> 00:12:35,582 You can tune in to more podcasts from 304 00:12:35,582 --> 00:12:37,822 Becker's Healthcare by visiting our podcast page at 305 00:12:37,822 --> 00:12:39,922 beckershospitalreview.com.