Never too early Tackling chronic disease to extend healthy life years A report from the Economist Intelligence Unit Sponsored by Abbott Never too early: Tackling chronic disease to extend healthy life years Contents Introduction About this research Executive summary Heading off chronic disease: New approaches to prevention l A preventable scourge l Changing incentives14 l Market-driven prevention16 The role of employers: Workplace initiatives to tackle chronic disease18 l Mission: Healthier workers19 l Healthier companies, too 20 l What works? 21 Managing chronic disease: Rethinking provision of care 23 l The separate worlds of acute and chronic care 23 l Managing chronic care: keys to success 25 l High touch and high tech 26 Conclusion 28 Appendix: Interview programme and expert panel participants 29 © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years Introduction “We are in the age of the old Let’s celebrate,” says Mary Baker, president of the European Brain Council The premise of her statement, especially for Europe, is indisputable The United Nations Population Division reports that life expectancy in Europe has risen by an average of ten years since 1960 and two years in the past decade alone It forecasts that average life spans across Europe will rise from 75 years currently to 82 years by 2050 This is of course good news, but even good news can have a dark side In the case of Europe’s longevity, the sunny outlook is clouded by the fact that not all those extra years will necessarily be healthy ones The advanced years of many Europeans will be prematurely burdened by the need to cope with one or more chronic diseases, the incidence of which is climbing alarmingly Moreover, the rising tide of chronic illness is threatening the viability of Europe’s healthcare systems, which are ill-equipped to cope financially, operationally or strategically with increasing numbers of long-term patients That said, increased longevity promises opportunities too, as the swelling ranks of older Europeans represents a largely untapped human resource To raise awareness of those opportunities, the European Union has established the European Innovation Partnership (EIP) on Active and Healthy Ageing, part of a broader programme aimed at improving co-ordination between the EU and member states to encourage innovation The specific aim of the EIP on Active and Healthy Ageing is to find ways to add an average of two healthy life years for each European by 2020 Like much of the debate around extending healthy life years, the EIP focuses almost exclusively on improving care for Europeans over the age of 65 Yet better care for the aged is only one aspect of ensuring healthy ageing; the other is ensuring that people arrive at old age in a healthy condition in the first place The health practices of people in their 40s and 50s—and much earlier as well—has a © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years significant impact on their health in their later years Indeed, some health experts suggest that the focus on health should begin at birth, and perhaps even before— in other words, that it is never too early to start taking steps that result ultimately in a healthier and longer old age “The strategy for healthy ageing should be a continuum from birth,” says Desmond O’Neill, president of the European Union Geriatric Medicine Society “The challenge is not to take the foot off the pedal.” This study hopes to make a contribution to European efforts to extend healthy life years by focusing on what can be done well before retirement to increase the odds for healthy longevity The focus is in particular on measures to prevent and manage chronic diseases, since these have the greatest impact on the health of older Europeans The research considers the effects of poor co-ordination among healthcare providers, governments, civil society, private employers and the public on making the necessary changes to the healthcare system to improve the healthy longevity of both individuals and the system It identifies best practice initiatives in prevention, early intervention and management of chronic diseases that can contribute to healthy ageing In addition, it highlights effective ways to shift the focus from reactive, hospital-based care of the sick towards a proactive, preventive and patient-centred approach to improving health © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years About this research In late 2011, with a view towards contributing to the debate surrounding the EU’s European Innovation Partnership on Active and Healthy Ageing, the Economist Intelligence Unit undertook this study of ways to manage the rising tide of chronic disease This research, which was sponsored by Abbott, focuses on tackling chronic disease as one of the chief ways of extending healthy life years in Europe As an initial step, the Economist Intelligence Unit convened a panel of experts on November 21st in Brussels to discuss the focus of the study This report is based on the insights gained in that discussion, as well as on extensive desk research and subsequent in-depth interviews with 35 experts in chronic disease and healthy ageing We would like to thank all participants in the expert panel and the interview programme, who are listed in the Appendix The Economist Intelligence Unit bears sole responsibility for the content of this study The findings and views expressed in the report not necessarily reflect the views of the sponsor Paul Kielstra was the principal researcher of this study Delia Meth-Cohn and Aviva Freudmann were the authors Conrad Heine, Trevor McFarlane and Stephanie Studer contributed research and interviews © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years Executive summary The promise of healthy ageing in Europe is clouded by the rising incidence of chronic disease These diseases, whose hallmark is a gradual and long-term deterioration of function rather than a sudden acute event, increasingly threaten both the quality of life of older Europeans and the ability of healthcare systems to cope with their demands In the absence of reforms in both the care of individual patients and the overall design of healthcare systems themselves, the rising tide of chronic illness threatens to overwhelm the resources of healthcare by mid-century, ensuring that ageing is a burden and not an opportunity for Europe Most of the work on healthy ageing, including the European Union’s Innovation Partnership on Active and Healthy Ageing, focuses on how to improve care for the aged This study refocuses attention on getting people to old age in a healthier condition by looking at what can be done throughout people’s lives to increase the odds for healthy longevity Here are some of the key findings of this research: l Chronic diseases threaten to overwhelm Europe’s healthcare system Between 70% and 80% of European healthcare costs are spent on chronic care, amounting to €700bn in the EU Chronic diseases account for over 86% of deaths in the EU l This scourge is largely preventable Scientists believe that much of the disease burden can be prevented, or at least substantially delayed, through a combination of primary prevention measures, screening and early intervention l An ounce of prevention is worth a pound of cure The “four basics” of primary prevention are already well known: a healthy diet, regular exercise, avoiding tobacco and eschewing excessive alcohol intake l Prevention also includes early diagnosis and intervention While primary prevention focuses on healthy living, secondary prevention (early screening and diagnosis) and tertiary prevention (early intervention to slow the progress of diseases identified) also play important roles in reducing the burden of chronic disease l It is never too early to tackle chronic diseases such as cardiovascular and respiratory illnesses, Type diabetes, cancer, dementia, kidney and liver diseases, obesity and being overweight Indeed, healthy practices begun in infancy—and perhaps even earlier, in vitro—can help to forestall the onset of disease l Care of chronic conditions has distinct needs compared to acute care, and must be refashioned accordingly To ensure appropriate care for chronic disease sufferers as well as free up medical resources for acute-care patients, © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years communities and healthcare systems should direct more resources to wellness, prevention and disease management programmes for chronic patients l Healthcare should be integrated and patient-centred to the greatest extent possible Integration of medical services and other services such as mental health, in-home sanitary care, and instruction in self-monitoring and self-care methods are crucial components of creating an integrated, patient-centred chronic care system This is particularly important for patients suffering from more than one chronic disease, who often must co-ordinate their own care among silo-like specialised care providers under the current system l Healthcare should be devolved as far as possible down the provider chain As part of patient-centred healthcare, patients should be encouraged to as much as possible for themselves, with appropriate support from a variety of providers—not all of them necessarily specialised doctors Pharmacists, nurses, community workers, home care workers and others can all play a part, and are often in a © The Economist Intelligence Unit Limited 2012 better position than doctors and hospitals to provide time-intensive coaching and personal attention to patients l Employers and health insurers have major contributions to make in fighting chronic disease Health and wellness programmes are increasingly being offered by progressive employers as a way to ensure that older workers are able to remain on the job longer Health insurers are also increasingly sponsoring health and wellness programmes as incentives to encourage healthy lifestyles and practices l Mental healthcare is an important part of the mix in the prevention and treatment of chronic illnesses Researchers have found that isolation and loneliness among those whose function is impaired owing to chronic disease aggravates their condition Several promising initiatives aim at reducing that loneliness through individual case management and personal health coaching In general, healthcare providers are increasingly incorporating mental health services as part of treatment for chronic-care patients Never too early: Tackling chronic disease to extend healthy life years Heading off chronic disease New approaches to prevention “An ounce of prevention is worth a pound of cure,” wrote American statesman Benjamin Franklin in the 18th century Although his dictum was meant to apply to all facets of life—and not only to medical cures—his wisdom is nowhere more applicable than in 21st century Europe Today in Europe, many pounds of cure are being expended to fight chronic illnesses that in many cases could have been prevented in the first place who have reached retirement age have had at least two chronic conditions Although Europeans are increasingly living longer on average, the high incidence of chronic disease at retirement age suggests that for far too many this longevity will not necessarily mean many years of healthy, full functioning For Europe’s healthcare systems—and the national budgets that largely support them—this trend also suggests an unhealthy future According to the European Public Health Alliance (EPHA), between 70% and 80% of European healthcare costs are spent on chronic diseases This corresponds to €700bn in the EU, and this figure is expected to rise in the coming years, according to the EPHA Worldwide, the figures are even more dramatic The World Economic Forum calculates that the global economic impact of the five leading non-communicable diseases (NCDs)—cardiovascular disease, chronic respiratory disease, cancer, diabetes and mental illhealth—could total US$47trn by 2030 (see Chart 1) Unless the rising tide of chronic disease is reversed, such costs—which A preventable scourge Chronic disease is shaping up as a modern-day scourge According to the European Chronic Disease Alliance, a coalition of medical professional organisations, over 100 million European citizens—or 40% of the population above the age of 15—have a chronic disease That proportion rises progressively through the age ranks, with the result that Europeans reaching retirement age are more likely than not to suffer from at least one chronic condition According to the World Health Organization (WHO), two out of three Europeans Chart Doubling the burden by 2030 Chronic disease cost burden, 2010 and 2030 (VSL estimates*) (US$ tr) 2010: total 22.8 14.8 0.5 5.1 2.4 High income Upper middle income Lower middle income Low income 2030: total 43.4 19.7 1.0 17.4 5.3 *The VSL approach is used to estimate the economic burden of NCDs in 2010 and to project that burden in 2030 The VSL data are taken to be the value of life of a representative median-aged member of the corresponding national population Constructing the VSL estimates/projections requires the estimation of DALYs in 2010 and 2030 Source: 'The Global Economic Burden of NCDs', World Economic Forum and Harvard School of Public Health, 2011 © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years include output loss as well as direct healthcare spending— could have a severe impact on national economies and their healthcare systems found that eating a Mediterranean diet, regular exercise, not smoking, and maintaining a healthy weight collectively added 15 years to an average woman’s life span and 8.5 years to an average man’s life span One of the main reasons healthcare systems around the world are ill-suited to dealing with chronic disease is that they were designed to respond to acute, short-term illnesses and injuries, rather than to prevent and manage the gradual, longterm deterioration that characterises chronic disease Indeed, the rising ride of chronic disease represents a sea change in the type of illnesses affecting people worldwide More than 60% of deaths worldwide are due to NCDs, killing 36 million people each year, according to the World Economic Forum Chronic diseases account for over 86% of deaths in the EU, according to the Chronic Disease Alliance “These measures are so well known as to be almost banal,” says Professor James Vaupel, founding director of the Max Planck Institute for Demographic Research in Rostock, Germany, and head of its Laboratory of Survival and Longevity “The bottom line is, you are more likely to reach age 80 if you listen to what your mother told you.” But the trend towards healthier living is weak, at best “People think they need expensive food to have a good diet, but the Mediterranean diet is cheap and smoking costs lots of money,” notes Piet van den Brandt, professor of epidemiology at Maastricht University and author of the Dutch study A 2010 study by the OECD and the European Commission found that over one-half of adults living in the EU are overweight or obese, and that the rate of obesity has more than doubled over the past 20 years (see Chart 2) Similarly, although smoking rates have fallen, smoking is still very much part of the culture in many parts of Europe Astoundingly, scientists believe that much of this scourge is preventable—or at least can be substantially delayed According to the WHO and the NCD Alliance, simple measures that fall under the rubric of “primary prevention”, such as eating a healthy diet, avoiding tobacco use and excessive alcohol, and increasing physical activity can prevent 80% of premature heart disease, 80% of Type diabetes and 40% of all cancers A recent large longitudinal study in the Netherlands Prevention is not only a matter of healthier living Early diagnosis and the right kind of early intervention and disease Chart Growing girths Overweight and obese populations in Europe, males (representative sample of countries) (%) Overweight Obese 50 50 Bulgaria Denmark England Finland France 43.5 45.0 39.2 30 Germany Italy Poland Note: Overweight defined as % Body Mass Index 25-29.9; and obesity defined as % Body Mass Index 30+ Source: International Association for the Study of Obesity, 2011 © The Economist Intelligence Unit Limited 2012 Russia Slovakia Spain 10 8.3 14.8 13.4 17.8 20 10.3 15.7 10.5 40 30.7 41.0 42.5 45.5 20.5 16.1 14.9 11.8 13.4 22.1 20 10 41.0 40.1 39.6 30 43.7 40 51.5 60 44.8 60 Sweden Switzerland Never too early: Tackling chronic disease to extend healthy life years management—known as secondary and tertiary prevention—can also make considerable contributions to reducing mortality from chronic diseases (For fuller definitions of primary, secondary and tertiary prevention, please see box, “Prevention: Three lines of defence”.) Shifting priorities Although policymakers are well aware of the shift in the nature of the burden on the healthcare system, that knowledge has yet to be translated into an overhaul of the system Funds are still directed in the same way they have been all along—to caring for hospital-bound patients, and to treating diseases after they occur rather than trying to prevent them from occurring Much of healthcare spending is still oriented towards single-organ and single-occurrence events—such as heart attacks or acute appendicitis—rather than on the less dramatic long-term deterioration of function associated with chronic disease As a result, most funds expended in the healthcare system are directed towards solving yesterday’s problems rather than today’s and tomorrow’s problems In particular, vast sums are directed towards fighting diseases when they are close to killing patients rather than earlier in life when they are not immediately life threatening “About 27% of [US] Medicare spend is in the last year of a patient’s life,” notes Dr Paul Keckley, executive director of the Deloitte Center for Health Solutions “The policy debate is, is it Prevention: Three lines of defence The medical system has developed a typology for the wide range of practices covered by the general term “prevention” Preventive measures are carried out by both individuals and healthcare providers, and fall into three general categories: l Primary: Primary prevention aims to protect healthy people from developing a disease in the first place, through such measures as good nutrition, regular exercise, avoiding tobacco and alcohol, and receiving regular medical check-ups Primary prevention may also extend to population-wide measures such as improving air and water quality, mass immunisation, and strengthening family and community ties to promote mental health l Secondary: After risk factors have been found to be present, and/or signs of an illness have actually appeared, secondary intervention consists of screening for illnesses, particularly when risk factors are present, and early intervention measures to slow the progress of the disease while it is still in its early stages For example, a patient with signs of a heart condition might take daily low dosages of aspirin to prevent a first or second heart attack Alternatively, secondary prevention might consist of an enhanced regimen of screening and monitoring to track the progress of the disease as well as monitor response to therapies and track any required adjustments in dosing In some cases, drug therapies can be introduced to delay or slow down development of a disease such as Alzheimer’s l Tertiary: For patients who already have illnesses such as diabetes, heart disease, cancer or chronic musculoskeletal pain, tertiary prevention consists of measures to slow down physical deterioration Such measures might include participating in cardiac or stroke rehabilitation programmes, joining chronic pain management groups, or participating in support groups for patients with mental or psychological problems While these measures are technically no longer strictly preventive—the patient has already been diagnosed with the disease—they help to limit the debilitating effects of the illness, and thereby improve quality of life and extend life years in comparative health © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years programme since 2008 All insureds with chronic diseases who meet certain criteria are eligible for a personal coach, who contacts the insured by telephone and, on a voluntary basis, supports the patient’s therapy, monitors its success, and increases the patient’s abilities of selfmanagement The key is the ongoing relationship built on trust between the coach and the patient, which creates an incentive for patients to co-operate The results are tangible When the programme began, the Techniker Krankenkasse launched a longitudinal study to track results and the outcomes so far are positive For every chronic disease, participants report significantly better subjective health than the control group These better results are saving the company money For patients with cardiac disease, lower rates of heart failure and heart attack could mean a very significant reduction in costs The final evaluation of the project’s outcome is planned for July 2013 In addition to creating incentives through personal reinforcement of healthy choices, insurers are starting to offer financial incentives for healthy behaviours, such as visiting doctors for screening purposes, and disincentives for unhealthy ones, such as smoking In Germany, several health insurers (Krankenkasse) are starting to offer rebates on healthcare premiums 16 © The Economist Intelligence Unit Limited 2012 to subscribers who prove they have made regular visits to a gym Similarly in South Africa, the US and Canada, the Discovery insurance company offers a points-based system of rewards for insureds who exercise, buy healthy foods or reach specified goals for athletic performance Participants earn points for specified healthy behaviours and thereby rise through various levels, from blue to gold—with rewards adjusted to starting levels of fitness As they rise through the fitness measurement system, participants are given rewards, ranging from reduced insurance premiums to expenses-paid holidays To support the programme, Discovery formed alliances with various partners, such as supermarkets to offer discounts on certain healthy foods, and with airlines to offer discounted flights This type of short-term reward, along with the reinforcement offered by measurement and personal attention, support a shift to healthy habits more decisively than the promise of a healthier life decades from now This insight underlies the development of healthy lifestyle and early diagnosis programmes among insurers and employers Policymakers, too, are experimenting with both carrots and sticks such as smoking bans, high taxes on unhealthy foods and subsidised rates for sports facilities Never too early: Tackling chronic disease to extend healthy life years The role of employers Workplace initiatives to tackle chronic disease Employers, too, can play a crucial role in tackling chronic disease early and an increasing number of companies are focusing on improving employee health A recent survey by Towers Watson, a human resources consultancy, found that while only 30% of companies in Europe, the Middle East and Africa (EMEA) had a global health strategy in place, a further 47% intended to introduce one in the next five years Although these strategies include numerous elements, in 77% of cases they currently or will involve wellness and health promotion The reason for the spread of employee health programmes is not altruism Chronic diseases exert a high toll on labour productivity (see Chart 4) The World Economic Forum estimated that high-income countries lose US$26trn in economic output each year as a result, and that translates into a concern for all large companies “What employers are really interested in is a healthy workforce today,” says Natalie-Jane Macdonald, UK manager of BUPA “But the things they also help individuals to be healthier as they move into old age.” The main hurdle with relying on businesses to be an integral part of the health puzzle is that healthcare is still relatively low on the business agenda—and companies are certainly not incentivised to invest heavily in employee health for the sake of a healthier retired population in the future Nevertheless, companies are increasingly seeing the business value of taking a more proactive approach to maintaining health A Harvard Business School study found that the return on investment of a Chart Output suffers Total economic cost of chronic disease, US, 2003 (US$ bn) Treatment expenditures (Total = US$277 bn) Lost economic output (Total = US$1,047 bn) 300 300 280 271 250 250 200 200 171 150 150 100 105 50 48 Cancers 33 Hypertension 65 46 Mental disorders Heart disease 100 105 94 50 45 Pulmonary conditions 27 Diabetes 14 22 Stroke Source: The Milken Institute, 2009 © The Economist Intelligence Unit Limited 2012 17 Never too early: Tackling chronic disease to extend healthy life years comprehensive, well-run programme could be as high as 600%, while the World Economic Forum’s head of health programmes, Dr Jané-Llopis, says “the most conservative figures are a return on investment of US$3-4 for every one US dollar.” Mission: Healthier workers There are three main driving forces for companies to introduce healthcare programmes, weighted differently across countries: the rising cost of covering employees’ healthcare costs; the shortage of skills and the need to retain workers as they get older; and the growing burden of absenteeism and low productivity through ill health US companies tend to be the most advanced in providing healthcare because they pay directly for medical costs “The US has the ‘advantage’ of being saddled with medical costs at corporate level, giving companies an incentive to improve the health of their employees,” says Sean Sullivan, president and chief executive of the Institute for Health and Productivity Management “Keeping employees out of hospital has a direct impact on the bottom line.” (For an example of a comprehensive corporate approach to preventive health, please see box, “Dow: A focus on prevention”.) German companies also feel the impact of rising healthcare costs passing through the system and raising employer contributions In addition, they are strongly motivated to tackle the growing skills shortage by keeping a steadily ageing workforce healthy and productive In the past, “companies fired people who were sick rather than working on improving the labour environment,” notes Professor Norbert Klusen of Germany’s Techniker Krankenkasse, a health insurance fund “That has changed completely Employers ask us to analyse absenteeism and create prevention programmes We have done so for thousands of companies and they are working quite successfully.” Klaus Böttcher, head of the department of performance and contract management for KKH Allianz, a German health insurer, has seen a similar change in attitudes as businesses recognise the implications of ageing populations Until very recently, companies encouraged early retirement as a way to maintain healthy workforces “Now company leaders realise that this was not a good idea,” he says “They are not able to find enough young, highly qualified workers, so they ask us to collaborate and offer prevention programmes.” Dow: A focus on prevention Dow is a global leader in corporate healthcare It started developing healthcare programmes ten years ago and has developed a comprehensive and strategic approach to preventive health A team of health promotion managers runs a broad variety of activities and initiatives all feeding into each other Dow Health Days, for example, focus on a specific issue (Walk at Dow Day, Dow No-Tobacco Day) There are opt-in six-week group programmes focusing on areas like stress resistance or weight management In addition, there is more targeted outreach through a Health Assessment Programme, which begins when employees join the company and 18 © The Economist Intelligence Unit Limited 2012 continues throughout their career, assessing health risks, followed by counselling and referral where necessary Dow has rolled out preventive health programmes for all its employees worldwide and claims the payback is substantial It has seen a 23% reduction in smoking among employees since 2004 and an improvement in weight at a time when the rest of the country is getting heavier Its targets are to reduce key indicators, such as average levels of smoking, body mass index, blood pressure and so on, by ten percentage points over ten years Never too early: Tackling chronic disease to extend healthy life years BMW has embraced this shift as a way to ensure that it remains competitive In 2007 the luxury German car company realised that the average age of its workers in its Dingolfing plant in Bavaria would rise from 39 to 47 over the next decade Rather than seeking to find and train younger workers, the company looked at redesigning production to help older workers keep working and remain healthy The first step was research BMW created Line 2017, with 41 volunteer employees who collectively matched the demographics that were expected to exist at the plant in that year They employed a research team to collect information from the employees on all the aches and pains they experienced on the job, as well as suggestions on how conditions might be improved to reduce or eliminate these Employees on the experimental line also voted on which of these changes they thought would be most desirable None of the innovations was huge: they included items such as softer flooring, adjustable worktables, easy exercises and lighter work shoes The health implications were, however, dramatic Absenteeism due to sick leave dropped from 7% to 2% The company also benefited financially Although the speed of the line was reduced by one-third, productivity increased by 7% and had an almost zero error rate When the experiment ended, the volunteers returned to their old lines, but BMW is rolling out the changes—and researching new ones—across all its Bavarian plants “Enabling older employees to be productive longer is not just about helping workers stay healthy; it’s about creating an environment conducive to health, activity, and continuous learning,” says Dr Michael Hodin, executive director of the Global Coalition on Aging “The result will help extend active and healthy years in employment and, more importantly, is the key to winning the competitiveness race of the 21st century,” he says Healthier companies, too Reducing absenteeism has been one of the major focuses of corporate healthcare programmes in the UK and France, where companies feel less direct pressure from rising medical costs Unilever has led the way in the UK with the launch of a pilot “Fit Business” programme in 2009, which was rolled out across the UK in 2010 after showing a decline of 19% in sick leave, a reduction in obesity of 26% and reduced risk of developing cardiovascular diseases At a cost of only £35,000, the returns from lower sick leave alone were threefold Unilever’s programme focuses on free health checks with clear explanations of what is being measured, and easy-to-use advice on nutrition and exercise The programme is evaluated on three criteria: absenteeism, employee involvement and a survey on the impact on attitudes towards work and life A French railway operator SCNF is also focusing on reducing absenteeism through its new healthcare scheme Average days lost to nonwork-related illness has been rising steadily, growing by 14% between 2007 and 2010 So the company launched a “Healthier Life” scheme in February 2012, following a successful pilot project in Brittany All workers will be screened for body mass index and those regarded as overweight will receive advice on diet and exercise and will be monitored on a monthly basis The company has set a target to reduce sick leave by 32% The focus of the programmes can vary depending on the needs of the staff One particularly serious concern for many firms is stress, which the Towers Watson survey listed as the leading health issue among EMEA companies KKH-Allianz developed an anti-stress programme for a hospital in Hannover where nurses faced high stress levels A multi-pronged approach, which combined advice on how to work in a way that reduced or eliminated stress, how to live with heightened stress levels and programmes in muscle relaxation, has reduced the number of sick days markedly, and let people stay on the job longer © The Economist Intelligence Unit Limited 2012 19 Never too early: Tackling chronic disease to extend healthy life years What works? Not all plans are successful The key is that “company leaders and department leaders want to collaborate,” says Mr Böttcher of KKHAllianz “It works only if you go top down into the company.” Mr Sullivan of the Institute for Health and Productivity Management stresses that although top executive leadership needs to make health into a corporate priority, ‘champions’ are needed to keep it a priority “You need to have mid-level management champions who help to build it into a culture, reinforce practices and values, with ‘cheerleading’ and encouragement, to get these policies down to employee levels,” he says He also emphasises the need for systematic screening “If you just rely on health risk assessments, you will miss half the people who don’t know they actually have a health problem,” he says Beyond that, the keys to success are: l Agree on simple measures and evaluate them with clear targets and key performance indicators l Make initiatives simple and convenient for participants l Be consistent and ensure that goals are supported by the work environment l Make it part of the culture of the business with support from the top l Allow flexibility—to recognise differences and the need to adapt l Make the programme long-term, be persistent and make sure it lasts l Ensure confidentiality 20 © The Economist Intelligence Unit Limited 2012 For enlightened firms where executives understand the utility, corporate wellness programmes can improve profits while helping employees to a healthier old age But for companies to become an integral part of national prevention and healthy ageing strategies, policymakers need to encourage workplace initiatives “The corporate employee is a representative of individuals in the community who are at risk of developing diabetes,” says Dr Barakat of the Imperial College London Diabetes Centre in Abu Dhabi “We frequently see patients who were very fit at school and university, but as soon as they get a desk job find it difficult to include exercise within their day-to-day activities The outcome is that weight begins to creep up, and then blood pressure begins to creep up, and then blood sugar levels begin to creep up.” Among the remedial solutions discussed to help solve this growing problem include sponsorship of football tournaments, walkathons, fitness challenges and nutrition coaching, among others Companies are also a crucial piece of the puzzle because they have an incentive to finance preventive services “You won’t get wellness and health promotion through a national health service, because they are focused on paying for illness—not on keeping people healthy,” says Mr Sullivan “But at the corporate level, they have a direct incentive to head it off.” Never too early: Tackling chronic disease to extend healthy life years Managing chronic disease Rethinking provision of care In the long term, the sustainability of Europe’s healthcare systems will depend on two factors: reorienting its focus from treating illness to promoting health, and improving the management of chronic diseases to make it both more effective and more cost-efficient Far from reducing the quality of healthcare, reforms that achieve these two goals will also help to extend healthy lives for all Europeans—allowing for a better allocation of medical resources and the continued use of expensive therapies where needed, while ensuring that chronic care addresses the real needs of the patients rather than that of specialised practitioners and hospitals The separate worlds of acute and chronic care What would it take to reorient the healthcare systems around the management of chronic diseases rather than treating them as just a species of acute care? Researchers have been working on ways to differentiate chronic care from acute care since the late 1990s, when three US institutes, the McColl Institute for Healthcare Innovation, the Robert Wood Johnson Foundation and Improving Chronic Illness Care (ICIC), created and developed a Chronic Care Model, designed as a support system for individuals with impaired functioning The approach requires care to revolve around interaction between an informed, active patient and a prepared, active practice team, drawing on resources from both the community and healthcare systems and pathways Level patients are the most complex cases requiring active disease management by medical teams In 2010 the RAND Corporation think tank evaluated 51 sites that had reorganised care in line with the model and found a much better chance that patients in such facilities received the correct therapy and saw improved outcomes For example, congestive heart failure patients treated in Chronic Care model facilities reduced the duration of their hospital stays by 35% on average There is a growing body of evidence in Europe too that a combination of medical and “social” care—the latter often involving both in-home visits and community-based activities for those able to participate—is more beneficial for patients A 2008 review of chronic care by the European Observatory on Health Systems found “sufficient evidence that single or multiple components of the model improve quality of care, clinical outcomes and healthcare resource use” The benefits A variant of the model was created by Kaiser Permanente, a US health insurance group It is based on the Kaiser Triangle, a notional, three-tiered pyramid with low-intervention patients at its base and high-intervention patients at its peak (see illustration) Level patients, the vast majority of chronic disease sufferers, mainly need support for self-management Level patients are higher risk, either because of multiple diseases or poor abilities to manage their own care, but can still be supported by teams using common protocols © The Economist Intelligence Unit Limited 2012 The 'Kaiser Triangle', illustrating different levels of chronic care Case Highly complex patients manage Disease management High-risk patients Supported self care 70-80% of people with chronic conditions Population-wide prevention Source: NHS and University of Birmingham 21 Never too early: Tackling chronic disease to extend healthy life years Chronic care in Denmark A good example of integrated care, involving doctors and community organisations, comes from Denmark The Østerbro Health Centre in Copenhagen is a joint venture of the city’s health administration, a large municipal hospital and local general practitioners It provides one-year rehabilitation programmes for patients with a range of chronic conditions This programme may include physiotherapy and co-ordination of various specialists a patient may need to see Central to the clinic’s offerings is the effort to teach the patient how are measurable in terms of improved levels of functioning, slowing down the progress of diseases, and reduced demand for acute intervention by doctors and hospitals (For an example of such an approach, please see box,: “Chronic care in Denmark”.) With the weight of increasing evidence, it is an apparent paradox that chronic care facilities, based around improving the functioning of patients and reducing demand for expensive acute care, are still an exception As a British general practitioner, Dr James Morrow, explains: “A lot of patients are stuck in hospital beds as bed blockers, and a lot of hospital admissions are triggered by a lack of readily available care in the community.” Improving the options for affordable care outside of hospitals could go a long way toward alleviating this problem There are three main constraints to expanding chronic care, none of which is insurmountable but all of which need concerted effort by many players to overcome The first is the need for task-shifting from doctors and hospitals to the patients themselves, as well as nurses, pharmacists, community workers or trained laypersons Creating this division of labour will, as a first step, require giving doctors and hospitals incentives to separate chronic from 22 © The Economist Intelligence Unit Limited 2012 to self-manage, including education specific to the disease, dietary counselling, and smoking cessation courses where necessary Early assessments of results showed that 86% of patients had started to exercise more and 42% had changed their diets Over 90% of general practitioners in the area have referred patients, and 96% of those thought the programme valuable to their patients acute care, and turn more of the former over to others Some European countries are already experimenting with such a shift The UK, for example, is experimenting with paying doctors based on their success in keeping patients out of hospital, and penalising hospitals whose discharged chronic-care patients are back within 30 days after being treated for an acute episode Patients, too, need help to understand that this shift of care responsibilities does not amount to “passing the buck” to less qualified personnel On the contrary, it tends to bring appropriate care closer to patients and make delivery of that care more personal Many of the needs of chronic-care patients, particularly older ones whose diseases have progressed, have to with combating isolation, lack of mobility, and difficulty with simple chores such as shopping, cooking and bathing Support in carrying out such everyday tasks, as well as personal contact with a care provider, can go a long way towards improving patients’ functioning and their quality of life— while also relieving the burden on the medical system Among other benefits, individual followup by non-medical providers can boost adherence to doctors’ prescribed therapies A transfer of care responsibilities to other medical professionals and to laypeople requires a supportive policy framework to avoid uneven Never too early: Tackling chronic disease to extend healthy life years levels of service and gaps in needed services A clearer division of labour between medical, paraprofessional and non-medical personnel could usefully be spelled out at national or regional level, with standards of care and clear protocols accompanying the transfer of responsibilities In a 2010 study for the University of Birmingham’s Health Services Management Centre, researchers Professor Jon Glasby and Kerry Allen identify a core of services that can be provided locally, such as co-ordinating and managing care programmes, recording performance and monitoring statistics But they also suggest a wider set of responsibilities at regional or national level to ensure a wellfunctioning system of care, including producing equipment, setting aims and objectives, developing and maintaining information management systems, and assuring quality at every stage The second obstacle to introducing chronic care on a broad scale is the difficulty of integrating many different players within and beyond the healthcare system, in the absence of incentives for them to co-operate In Europe, some of the best examples of well-functioning community care come from small, homogenous communities, like Østerbro, where achieving consensus and working together is relatively simple In some rural regions, particularly in southern Europe, institutions such as pharmacies already play an active role in dispensing medical advice to individuals, acting as a parallel support system With proper training and standard-setting, this approach could be used on a broader scale throughout Europe, not only in the case of pharmacists but also with nurses, community workers and others The third obstacle is embedded in the financial incentives surrounding caring for chronic disease sufferers Any change in the status quo is bound to have winners and losers And although patients may ultimately be the winners, in the short term opening up community-based chronic care facilities can mean closing down hospitals, or reducing their funding This is a political decision, and requires politicians and policymakers who are willing to take responsibility for the impact on current players Managing chronic care: keys to success Several important lessons about what works best have already emerged from the early experiments with restructuring the care of chronic disease patients away from the acute care model One is that chronic-care patients should be as involved as possible in designing and carrying out their own care, avoiding medical “diktats” wherever possible This approach has a practical side: ultimately, patients will be in charge of taking their medicine or not, doing their exercise or not, avoiding harmful foods or not, calculating their insulin requirements or not A patient who has been involved in the planning of a care regimen, and who understands the reasons for the health measures prescribed as well as their practical implementation, is a patient more likely to what is necessary to slow the progress of their disease Beyond that, a range of practical support for patients should be readily available when needed For example, a diabetic who has difficulty calculating the total calories associated with various foods may benefit from a simple calculator with built-in calorie counts for different foods A more maths-challenged diabetes patient may require an implanted “glucometer” to measure glucose levels and receive alerts from a remote support person— perhaps a nurse on duty—concerning how much insulin is required Access to advice and support can be made available through telephone hotlines, e-mail and social media forums, instant-messaging systems, and drop-in centres for those who prefer consultations in person Improving adherence to a medical regime is one of the key goals set by the European Innovation Partnership for improving healthy ageing—and it is not just a problem for the aged © The Economist Intelligence Unit Limited 2012 23 Never too early: Tackling chronic disease to extend healthy life years Patients may also need ongoing support to ensure that medications they take for one chronic disease does not aggravate the symptoms of another disease It is increasingly common for patients, particularly in advanced years, to suffer from more than one chronic disease In such cases, general practitioners, community-based nurses and other caregivers may be in a better position than medical specialists—who tend to focus on one disease at a time—to instruct patients on how to ensure appropriate responses to several medical issues simultaneously Coordination may also involve calling upon different resources—transport, in-home care, access to rehabilitation facilities, among others—where the patient may not have the wherewithal to that for himself or herself New technologies play an increasingly important role in facilitating the transfer of chronic care from doctors’ offices and hospitals to community centres and patients’ own homes In particular, telematics and e-health systems are increasingly coming into play Telematics technologies lend themselves to remote diagnosis—as, for example, when sensors transmit readings of patients’ vital signs, blood sugar levels and the like to a medical professional who can alert the patient to respond to dangerous levels Electronic health systems—which can share individual patient data and population-wide health information across various healthcare settings—can help to improve tracking of treatments for different diseases This is an especially useful tool when more than one disease is present in a single individual At a more sophisticated level, imaging technologies can aid in identifying indicators of disease, as well as helping treatment and monitoring As noted above, the fast-developing science of genomics is helping doctors to identify at-risk populations, while screening technologies are increasingly sophisticated in detecting disease indicators in individuals Moreover, telecommunications—online or by videoconference or simply by mobile phone—can 24 © The Economist Intelligence Unit Limited 2012 help to reduce the isolation of those whose illnesses limit their mobility, thereby supporting their mental health High touch and high tech The risk associated with some of the new technologies is that time-pressed caregivers will substitute medical devices and drugs for personalised care, perhaps out of a wish to use the latest and best technology available even if a lower-tech solution might be more appropriate “There is a real danger of overmedicalising normality, and creating dependent patients—patients who believe they are ill when they are normal for their age,” says Dr Morrow “The medical profession has always had the ability to encourage dependency It requires a dedicated team to avoid dragging patients into medical need.” Clearly, the solution is to focus on providing the right treatment at the right dose for each patient, but in the context of personalised attention wherever possible—in effect combining high touch and high tech There is growing evidence that the high-touch, personal approach is a crucial and often neglected part of the package Social psychologists are making strides in understanding the links between maintaining health—or at least avoiding rapid deterioration— and maintaining good connectedness with others, whether family members, friends, work colleagues or the broader community Staying active and connected is increasingly seen as a necessary component of a healthy lifestyle, and one that contributes to extending healthy life years The obverse is also true: isolation and loneliness aggravate many disease symptoms The effort to promote connectedness is a broad-based one, involving local government, community leaders, urban planners and many others The aim is to design communities — including housing, transport, shopping areas and public gathering places—in a way that promotes activity and interactions with others This trend Never too early: Tackling chronic disease to extend healthy life years fits well with efforts to shift the focus of care from hospitals to community clinics, day centres and private homes as much as possible The focus is on enabling as normal a lifestyle as possible for chronic disease patients It is part of both the ounce of prevention—slowing the progress of diseases—and the pound of cure for those suffering from both illness and isolation © The Economist Intelligence Unit Limited 2012 25 Never too early: Tackling chronic disease to extend healthy life years Conclusion When it comes to tackling chronic disease to extend healthy life years, the core problems are clear, and so are the solutions On the one hand, lifestyle-determined chronic illnesses are exploding as the population ages, pushing up costs in a way that threatens the sustainability of healthcare systems and many countries’ national budgets On the other, healthcare systems are still focused on treating acute cases and are illdesigned to cope with these growing demands So far, the responses of all the major players in Europe have been scattered and ill-coordinated The European Innovation Partnership on Active and Healthy Ageing pointed to this fragmentation as one of the main barriers to caring effectively for those over 65 But the same weakness holds for reshaping the way healthcare is assessed both to prevent and to manage chronic diseases before people reach old age The solution to the disjuncture between the growth in chronic disease and the focus of the medical system on acute care require, first and foremost, a reorientation of healthcare to focus on prevention rather than only on treating the sick The focus on prevention should take a variety of forms, including promoting the well-known basics of a healthy lifestyle and the use of secondary and tertiary prevention to detect and diagnose disease early, delay its onset and slow its progress 26 Beyond that, solutions to managing chronic disease go far beyond the traditional healthcare sector This requires entirely new forms of partnership and co-operation among a broad range of actors, including various levels of government, healthcare providers, insurers, private companies as producers of goods and services and as employers, and not least, individuals The focus of their concerted action should be on changing behaviour and fighting chronic diseases early on, rather than allowing them to develop and become even larger problems This research has highlighted examples of successful initiatives and pilot programmes to tackle chronic disease and promote healthy longevity Although these represent isolated examples, they demonstrate that changes can be successfully made by medical providers, insurers, employers and entire communities This report has identified some of the obstacles to reforming healthcare to tackle chronic disease, but has also highlighted possible solutions to the problem of an unsustainable burden of chronic disease in the future The key is for the various players to act in concert to fight chronic disease, to boost the chances that the bonus of greater longevity will be converted into the even greater blessing of healthy longevity © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years Appendix Interview programme and expert panel participants l Mark Butler, minister of ageing, mental health and social inclusion, Australia Note The Economist Intelligence Unit hosted an expert panel meeting on the subject of healthy ageing in Brussels on November 21st 2011 Panel members are indicated in the following list with an asterisk (*) We would like to thank all of the following individuals, listed alphabetically by surname, for their contributions to this research: l Lynda Anderson, director, Healthy Aging Program, Centers for Disease Control, USA l Maha Taysir Barakat, OBE, medical director at the Imperial College London Diabetes Centre in Abu Dhabi l Professor Klaus Böttcher, head of the department of performance and contract management, KKH-Allianz, Germany l Jacqueline Bowman*, executive director, EPPOSI (European Platform for Patients’ Organisations, Science and Industry) l Cristina Gutierrez Cortines*, member, European Parliament (Spain) l David Forrest*, senior vice-president, Nutrition International Operations, Abbott l Helmut Gohlke, internist and cardiologist, and Board member, German Heart Foundation l Oliver Harrison, director of Public Health and Policy, Government of Abu Dhabi l Mary Baker, MBE, president, European Brain Council, UK l John Beard, director, Department of Ageing and Life Course, World Health Organization, Switzerland l David Byrne*, former European Commissioner; patron, Health First Europe l Unni Hembre, president, European Federation of Nurses Associations, Belgium l Michael Hodin, executive director, Global Coalition on Aging, USA l Eva Jané-Llopis, head of health programmes, World Economic Forum, Switzerland l Paul H Keckley, executive director, Deloitte Center for Health Solutions, USA l Hal Kendig, professor of ageing and health, University of Sydney l Norbert Klusen, CEO, Techniker Krankenkasse, Germany © The Economist Intelligence Unit Limited 2012 27 Never too early: Tackling chronic disease to extend healthy life years l Peggy Koopman-Boyden, professor of social gerontology, National Institute of Demographic and Economic Analysis, New Zealand Prevention in Clinical Practice, Sweden l Natalie Jane Macdonald, managing director, BUPA, UK l Pascale Richetta*, vice-president, Western Europe and Canada, Proprietary Pharmaceuticals Division, Abbott l Johannes FE Mann, professor of medicine, Friedrich Alexander University of Erlangen; head of Department of Nephrology, Hypertension and Rheumatology, Schwabing General Hospital, Germany l James Morrow, general practitioner, UK l Sophie O'Kelly, head of European affairs, European Society of Cardiology, France l Desmond O’Neill, president, European Union Geriatric Medicine Society, UK l David Oliver, national clinical director for older people, National Health Service, UK l Lene Otto*, associate professor and programme leader, Centre for Healthy Aging, University of Copenhagen l Anne Sophie Parent, secretary-general, AGEPlatform Europe, Belgium l Joep Perk, cardiologist and professor of health sciences, chairman of the Joint European Societies’ Task Force for Cardiovascular 28 © The Economist Intelligence Unit Limited 2012 l Walter Ricciardi*, president, European Public Health Association, Netherlands l Bernat Soria*, former minister of health, Spain l Sean Sullivan, president and chief executive officer, Institute for Health and Productivity Management, USA l Axel Boersch Supan, head, Munich Centre for the Economics of Aging, Germany l Professor Andre Uitterlinden, director, Netherlands Consortium for Healthy Aging l Piet van den Brandt*, professor of epidemiology, Maastricht University l James Vaupel, founding director, Max Planck Institute for Demographic Research, Germany l Petra Wilson, director, public sector healthcare team, Cisco Internet Business Solutions Group, Belgium l Derek Yach, senior vice-president of Global Health and Agricultural Policy, Pepsi-Cola, USA While every effort has been taken to verify the accuracy of this information, neither The Economist Intelligence Unit Ltd nor the sponsor of this report can accept any responsibility or liability for reliance by any person on this white paper or any of the information, opinions or conclusions set out in this white paper Cover image - © sjlocke/iStockPhoto GENEVA Boulevard des Tranchées 16 1206 Geneva Switzerland Tel: (41) 22 566 2470 Fax: (41) 22 346 93 47 E-mail: geneva@eiu.com LONDON 26 Red Lion Square London WC1R 4HQ United Kingdom Tel: (44.20) 7576 8000 Fax: (44.20) 7576 8500 E-mail: london@eiu.com FRANKFURT Bockenheimer Landstrasse 51-53 60325 Frankfurt am Main Germany Tel: +49 69 7171 880 E-mail: frankfurt@eiu.com DUBAI PO Box 450056 Office No 1301A Thuraya Tower Dubai Media City United Arab Emirates Tel: +971 433 4202 E-mail: dubai@eiu.com PARIS rue Paul Baudry Paris, 75008 France Tel: +33 5393 6600 E-mail: paris@eiu.com [...]... employers Policymakers, too, are experimenting with both carrots and sticks such as smoking bans, high taxes on unhealthy foods and subsidised rates for sports facilities Never too early: Tackling chronic disease to extend healthy life years 2 The role of employers Workplace initiatives to tackle chronic disease Employers, too, can play a crucial role in tackling chronic disease early and an increasing... both illness and isolation © The Economist Intelligence Unit Limited 2012 25 Never too early: Tackling chronic disease to extend healthy life years Conclusion When it comes to tackling chronic disease to extend healthy life years, the core problems are clear, and so are the solutions On the one hand, lifestyle-determined chronic illnesses are exploding as the population ages, pushing up costs in a... improving healthy ageing—and it is not just a problem for the aged © The Economist Intelligence Unit Limited 2012 23 Never too early: Tackling chronic disease to extend healthy life years Patients may also need ongoing support to ensure that medications they take for one chronic disease does not aggravate the symptoms of another disease It is increasingly common for patients, particularly in advanced years, ... with others This trend Never too early: Tackling chronic disease to extend healthy life years fits well with efforts to shift the focus of care from hospitals to community clinics, day centres and private homes as much as possible The focus is on enabling as normal a lifestyle as possible for chronic disease patients It is part of both the ounce of prevention—slowing the progress of diseases—and the pound... have an incentive to finance preventive services “You won’t get wellness and health promotion through a national health service, because they are focused on paying for illness—not on keeping people healthy, ” says Mr Sullivan “But at the corporate level, they have a direct incentive to head it off.” Never too early: Tackling chronic disease to extend healthy life years 3 Managing chronic disease Rethinking.. .Never too early: Tackling chronic disease to extend healthy life years better to reinvest those resources in preventative management of chronic disease, or is it better to spend an inordinate amount of resources on endof -life care.” Similarly in Europe, the Organisation for Economic Cooperation and Development... recognising chronic disease management as a separate focus © The Economist Intelligence Unit Limited 2012 Never too early: Tackling chronic disease to extend healthy life years for healthcare in Europe is now creating an obstacle for its better diagnosis and prevention “EU policy does not include any disease- specific policies except for cancer This is a huge barrier for cardiovascular disease, ” says... continued for many years: between 1972 and 2002, average serum cholesterol levels dropped by around 18% Deaths from coronary heart disease fell by 87% between 1972 and 2002, compared with a decline of 75% in the entire country © The Economist Intelligence Unit Limited 2012 15 Never too early: Tackling chronic disease to extend healthy life years programme since 2008 All insureds with chronic diseases who... Limited 2012 11 Never too early: Tackling chronic disease to extend healthy life years The same questions have been raised in screening and early intervention for respiratory and for cardiovascular illnesses To ensure they detect as many real cases as possible, clinicians may use a highly sensitive measurement, which may also yield some false positives “The classic example is asthma: we tend to diagnose... at a time when the rest of the country is getting heavier Its targets are to reduce key indicators, such as average levels of smoking, body mass index, blood pressure and so on, by ten percentage points over ten years Never too early: Tackling chronic disease to extend healthy life years BMW has embraced this shift as a way to ensure that it remains competitive In 2007 the luxury German car company ... Intelligence Unit Limited 2012 25 Never too early: Tackling chronic disease to extend healthy life years Conclusion When it comes to tackling chronic disease to extend healthy life years, the core problems... services as part of treatment for chronic- care patients Never too early: Tackling chronic disease to extend healthy life years Heading off chronic disease New approaches to prevention “An ounce of... Limited 2012 Never too early: Tackling chronic disease to extend healthy life years better to reinvest those resources in preventative management of chronic disease, or is it better to spend an