For decades, health care professionals and population health experts have warned that the U.S. has a crisis of chronic disease. About 60% of Americans have at least one chronic condition and 40% have two or more. The total cost of managing and treating chronic conditions is staggering. The Centers for Disease Control and Prevention (CDC) estimates that 90% of all health care costs in the U.S. go toward treating chronic disease and mental health — about $3.7 trillion a year. Any efforts to reduce total health care costs in the U.S. must address these chronic health conditions.
While some chronic conditions are genetic, many are exacerbated by or the result of lifestyle choices, including excess alcohol consumption, physical inactivity, tobacco use, and unhealthy diet.
Most providers and health plans have programs available to help people improve their lifestyles to reduce the risk of developing chronic disease. But for people who already have these conditions, active chronic care management is necessary to maintain health and avoid complications.
When the COVID-19 pandemic hit the U.S. in 2020, we saw the significant toll it took on people with underlying health conditions. Age was the strongest risk factor for more severe COVID-19 symptoms. But the CDC also released a report documenting higher risk of “severe COVID-19 outcomes” for people with 19 different chronic diseases.
Further complicating the situation was the fact that some people were afraid to go to a hospital or doctor’s office during the pandemic. Millions of patients skipped appointments, tests, and screenings that are essential for managing chronic disease. Missing routine care to manage chronic conditions can lead to worsening health. Eventually, someone who doesn’t get proper chronic care management could end up needing costly care in the ER or hospital.
There are two key reasons that health care costs are so high for someone with a chronic health condition:
People with chronic health conditions often need more care than people without a chronic disease. Patients with these conditions may require:
The second reason chronic care costs are often higher is the increased risk they carry for ending up in an emergency room or hospital. People with these conditions may experience emergencies or flare-ups that necessitate emergency care. Some of these visits result in hospital admission when the condition has progressed and requires more intensive treatment.
There are also situations where people with chronic diseases seek care in the ER unnecessarily. One study found that patients with one or more chronic conditions and “highly fragmented care” were 13% to 14% more likely to visit the ER. Fragmented care often means lack of continuity in care and treatment plans. These people may not have a primary care provider to coordinate care and monitor their health over time.
Another study found that patients with chronic diseases contributed to 60% of all ER visits, and 4.3 million visits were likely preventable. Avoiding these preventable visits would save $8.3 billion a year in health care costs. There is no single reason for unnecessary ER visits, but reasons include:
The high costs of chronic diseases necessitate a more comprehensive approach by health care providers and health plans. Chronic care management programs are one of the most efficient and effective ways to address the ongoing care needs of this patient population and lower total care costs.
Effective care management programs:
Many of these programs are now available through health care plans such as Highmark. Health plans and providers regularly review data to identify patients who might need this care, then set up outreach to discuss the benefits. Once a patient is enrolled, they can take advantage of:
Both Medicare and private insurance now reimburse providers for non-face-to-face services monitoring patients with two or more chronic conditions. Results from some of the most successful chronic care management programs show that they are an effective way to lower costs.
While chronic disease does contribute to a significant amount of excess health care spending, it’s not the only reason for high costs in the U.S. We take a deep dive into several things that influence total cost of care in this series:
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All references to “Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health benefit administration and/or to one or more of its affiliated Blue companies. This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.
Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal. ®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Wholecare or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company, Highmark Wholecare or Highmark Senior Health Company. PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield or Highmark BCBSD Health Options Inc. d/b/a Highmark Health Options. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company, or Highmark Senior Solutions Company or Highmark Health Options West Virginia Inc. d/b/a Highmark Health Options. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card . Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
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