A recent 60 Minutes segment on end of life care described the burgeoning financial costs of treating chronic illness and ameliorating the pain of dying. Last year, Medicare paid $50 billion to hospitals and doctors for costs associated with treatments in the last two months of life. It costs upwards of $10,000 a day to keep a patient alive in the ICU, and by law, Medicare cannot reject any treatment based upon cost or feasibility of delivering a better quality of life. It is clear that at some point, our nation must have a rational discussion about end of life and how to adapt the health care system to properly address the biological inevitability while respecting its emotional delicacy. However, given the political volatility and ethical issues surrounding end of life care, it seems prudent to direct our energy towards maintaining a healthy, vibrant quality of life.
Although life expectancy is increasing, this no guarantee that that those additional years will be disease-free. Chronic diseases—such as heart disease, cancer, and diabetes—are among the most common and costly health problems in the United States. In 2005, one out of every two Americans was living with a chronic illness, and one in four of these individuals have one or more limitations in daily living. The management of chronic conditions is a burden on health care resources, and a life with a chronic condition is compromised in quality. As the pace of technological and pharmaceutical progress accelerates, we must continually reassess whether or not each advance is simply extending life, or rather, enhancing the quality of that life and reducing the burden of morbidity.
The compression of morbidity concept was originated by James Fries, a professor at the Stanford University School of Medicine, and is based upon the hypothesis that it is possible to delay the onset of chronic illness even though corresponding increases in longevity will be modest.1-2 If we determine ways to maximize this compression of morbidity, this effectively reduces the period of suffering from a chronic disease to the time of death. Isn’t this what living your best life is all about?
Indeed, studies have shown that taking gradual steps to lead a healthier lifestyle—increasing physical activity, eating a healthy diet, minimizing alcohol consumption, and quitting tobacco use—can reduce and postpone age-related morbidity.3 Fries et al. conducted a 12-year study that monitored the effect of lifestyle-related risk factors- smoking, physical inactivity and weight status in a group of 418 deceased members of an aging cohort. Disability scores were modeled for each risk group to assess level and rate of change in an individual’s functional status in the years before death. Fries discovered that the risk free group showed an average disability score of zero in the 10-12 years before death without accelerated functional decline until immediately before death. In contrast, the group with two or more risk factors maintained a greater level of disability and showed advanced decline in the 1.5 years before death.4 A healthy lifestyle won’t necessarily increase total lifespan, but it will increase the likelihood of postponing the onset of functional disability and associated suffering that occurs before death. This is one of many reasons that 21st century physicians and allied health professionals must practice lifestyle coaching and collectively champion prevention.
Although chronic disease is an increasing epidemic and we as a nation should have better health outcomes, the push for health care reform is financially motivated—U.S. health care spending is unsustainable at 17% of GDP, Medicare and Medicaid are bursting the budget, and the ensuing deficit threatens America’s competitive edge in the globalized world. Those who analyze the quality, health-related benefits of reform must connect and translate their findings into cost-effectiveness in order to garner public attention and impact policy decisions. Thus for lawmakers to whom this plea may not be as salient, the compression of morbidity has important fiscal implications for the future of health care.
The key is to find and target the root of rising health care costs. Certainly insurance companies have increased premiums way above acceptable levels. Insurance reform is imperative. Yes, the pharmaceutical industry charges an astronomical sum for name-brand drugs. Comparative effectiveness testing is necessary and an open market should create competition among prescription drugs and insurance policies alike. And yes, physicians often practice defensive medicine and order an array of tests to protect themselves from malpractice suits. Tort reform and alternatives to fee-for service should be explored. The key point, however, is that we pay for health care when we are sick. If costs are escalating—whether in the insurance market, medical devices, or in the delivery of care—this stems from the fact that people are getting sicker, staying sicker for a longer time, and consuming more health care resources. And this strain will only increase when 50 million baby boomers soon enter the later stages of life.
The new health care law shines a spotlight on prevention in an effort to reduce the huge toll of preventable diseases. Often overshadowed, but potentially powerful provisions of the law are designed to counter the forces that encourage sedentary lifestyles, smoking, and high-calorie diets. For example, all chain restaurants must now provide nutrition information on their menus in an effort to heighten consumer awareness. Tucked away in the complexities of insurance reform is the stipulation that insurance companies must cover all recommended screenings, preventive care and vaccines, without charging co-pays or deductibles. Those individuals whose care is covered by Medicare will get free annual physicals. And Medicaid will cover drugs and smoking cessation counseling for pregnant women. Finally, the federal government has created a trust fund for bicycle paths, playgrounds, and hiking trails to build a healthy, active environment.
Currently, the precious resources allocated toward preventive services are in peril amidst discussions of budget cuts. Prevention dollars have been labeled a “slush fund”, and recently, the House Energy and Commerce Committee’s Health Subcommittee voted to repeal the Prevention and Public Health Fund that was created in the health care reform bill. Alas, it seems that prevention is too amorphous a concept. Perhaps prevention is less certain because it relies too heavily on individual initiative rather than top-down structural reform and regulation. Or perhaps the benefits are too far off in the future to be immediately salient? Or maybe we as individuals do not see how our own health and well-being impacts society at large? Whatever the case may be, if we are not motivated by the opportunity of a higher quality of life, let’s promote prevention to contain health care costs by compressing morbidity and reducing costs associated with chronic diseases. Reducing the federal deficit will be a long-term journey, much like the road towards healthy living. We must understand that physical and fiscal health are not at odds in this process; they are sides of the same coin.
1. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. Jul 17 1980;303(3):130-135.
2. Fries JF. The compression of morbidity. Milbank Mem Fund Q Health Soc. Summer 1983;61(3):397-419.
3. Fries JF. Frailty, heart disease, and stroke: the Compression of Morbidity paradigm. Am J Prev Med. Dec 2005;29(5 Suppl 1):164-168.
4. Hubert HB, Bloch DA, Oehlert JW, Fries JF. Lifestyle habits and compression of morbidity. J Gerontol A Biol Sci Med Sci. Jun 2002;57(6):M347-351.
5. Fries JF. Physical activity, the compression of morbidity, and the health of the elderly. J R Soc Med. Feb 1996;89(2):64-68.