Timothy M. Dall

OBJECTIVE: To evaluate the clinical, economic, and social benefits and costs of evidence-based obesity treatment among commercially insured adults. RESEARCH DESIGN AND METHODS: Using a Markov-based microsimulation model, we projected 5-year clinical and economic outcomes of intensive lifestyle management, obesity medications, and metabolic/bariatric surgery, drawing on data from clinical trials, national surveys, and economic studies. RESULTS: This analysis focused on 47.3 million commercially insured adults with obesity who lacked access to treatment through existing clinical pathways. Over 5 years, cumulative medical savings per person ranged from $2,908 for lifestyle intervention to $2,450–$7,304 for obesity medications and $12,001 for surgery among adults without preexisting diabetes or cardiovascular disease. At the population level, access to treatment would yield 5-year benefits of $9.7 billion in medical savings, $25.8 billion in productivity gains, $38.8 billion in quality-of-life value, and $29.6 billion in mortality-reduction benefits, requiring $44.7 billion in total investment. Combined benefits produced net social value of $59.1 billion, with a $2.35 return per dollar invested and positive returns as early as the second year. CONCLUSIONS: Obesity treatment generates substantial social benefits through improved health outcomes and productivity gains. Medical and disability cost savings and workplace productivity improvements combined could recover 81% of treatment investment. Employees effectively finance coverage through premiums and reduced wages, and comprehensive benefit design that includes health outcomes and quality-of-life improvements more accurately reflects societal treatment value. Coverage decisions based solely on employer economic returns underestimate the full societal value of expanding coverage.

OBJECTIVE: To quantify the preventable disease burden and foregone economic benefits resulting from maintaining current limited access to obesity treatment among U.S. adults. RESEARCH DESIGN AND METHODS: Using microsimulation modeling, we projected 10-year health and economic outcomes under three scenarios: current limited treatment access, expanded access to intensive lifestyle management or earlier-generation medications, and expanded access to glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists. The model simulated individual-level trajectories for 107.6 million adults with obesity across commercial insurance, Medicare, Medicaid, and uninsured populations, incorporating clinical outcomes, medical expenditures, productivity losses, quality-adjusted life-years, and mortality. RESULTS: By forgoing treatment, an estimated 5.3 million preventable deaths, 5.0 million diabetes cases, 5.5 million heart failure cases, 2.8 million strokes, 1.3 million myocardial infarctions, and 1.5 million obesity-related cancers would occur over 10 years. The economic cost of inaction totals $10.5–$13.3 trillion in foregone benefits, including $1.8 trillion in avoidable medical expenditures, $3.0 trillion in lost productivity, and $5.6–$8.5 trillion in diminished quality of life. Over the 10-year period, expanded access to intensive lifestyle management or earlier-generation medications would prevent 3% of deaths and 17–23% of major complications, while expanded access to incretin-based therapies would prevent 9% of deaths and 22–31% of complications. CONCLUSIONS: Maintaining current limited treatment access results in substantial preventable disease burden and significant foregone economic benefits. Conventional framing focuses on intervention costs while ignoring ongoing expenses of untreated disease. This reframes the cost question from whether we can afford treatment to whether we can afford the consequences of inadequate access and intervention.

Objective: The aim of this study was to assess the current and future adequacy of physiatrist supply in the United States. Design: A 2019 online survey of board-certified physiatrists (n = 616 completed, 30.1% response) collected information about demographics, practice characteristics, hours worked, and retirement intentions. Microsimulation models projected future physiatrist supply and demand using data from the American Board of Physical Medicine and Rehabilitation, national and state population projections, American Community Survey, Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and other sources. Results: Approximately 37% of 8853 active physiatrists indicate that their workload exceeds capacity, 59% indicate that workload is at capacity, and 4% indicate under capacity. These findings suggest a national shortfall of 940 (10.6%) physiatrists in 2017, with substantial geographic variation in supply adequacy. Projected growth in physiatrist supply from 2017 to 2030 approximately equals demand growth (2250 vs. 2390), suggesting that without changes in care delivery, the shortfall of physiatrists will persist, with a 1080 (9.7%) physiatrist shortfall in 2030. Conclusion: Without an increase in physiatry residency positions, the current national shortfall of physiatrists is projected to persist. Although a projected increase in physiatrists’ use of advanced practice providers may help preserve access to comprehensive physiatry care, it is not expected to eliminate the shortfall.

OBJECTIVE: This study was conducted to update national estimates of the economic burden of undiagnosed diabetes, prediabetes, and gestational diabetes mellitus (GDM) in the United States for year 2017 and provide state-level estimates. Combined with published estimates for diagnosed diabetes, these updated statistics provide a detailed picture of the economic costs associated with elevated blood glucose levels. RESEARCH DESIGN AND METHODS: This study estimated medical expenditures exceeding levels occurring in the absence of diabetes or prediabetes and the indirect economic burden associated with reduced labor force participation and productivity. Data sources analyzed included Optum medical claims for ∼5.8 million commercially insured patients continuously enrolled from 2013 to 2015, Medicare Standard Analytical Files containing medical claims for ∼2.8 million Medicare patients in 2014, and the 2014 Nationwide Inpatient Sample containing ∼7.1 million discharge records. Other data sources were the U.S. Census Bureau, Centers for Disease Control and Prevention, and Centers for Medicare & Medicaid Services. RESULTS: The economic burden associated with diagnosed diabetes (all ages), undiagnosed diabetes and prediabetes (adults), and GDM (mothers and newborns) reached nearly $404 billion in 2017, consisting of $327.2 billion for diagnosed diabetes, $31.7 billion for undiagnosed diabetes, $43.4 billion for prediabetes, and nearly $1.6 billion for GDM. Combined, this amounted to an economic burden of $1,240 for each American in 2017. Annual burden per case averaged $13,240 for diagnosed diabetes, $5,800 for GDM, $4,250 for undiagnosed diabetes, and $500 for prediabetes. CONCLUSIONS: Updated statistics underscore the importance of reducing the burden of prediabetes and diabetes through better detection, prevention, and treatment.

The Centers for Disease Control and Prevention estimates that 28.9 million adults had diabetes in 2012 in the US, though many patients are undiagnosed or not managing their condition. This study provides US national and state estimates of insured adults with type 2 diabetes who are diagnosed, receiving exams and medication, managing glycemic levels, with diabetes complications, and their health expenditures. Such information can be used for benchmarking and to identify gaps in diabetes detection and management. The study combines analysis of survey data with medical claims analysis for the commercially insured, Medicare, and Medicaid populations to estimate the number of adults with diagnosed type 2 diabetes and undiagnosed diabetes by insurance type, age, and sex. Medical claims analysis used the 2012 de-identified Normative Health Information database covering a nationally representative commercially insured population, the 2011 Medicare 5% Sample, and the 2008 Medicaid Mini-Max. Among insured adults in 2012, approximately 16.9 million had diagnosed type 2 diabetes, 1.45 million had diagnosed type 1 diabetes, and 6.9 million had undiagnosed diabetes. Of those with diagnosed type 2, approximately 13.0 million (77%) received diabetes medication-ranging from 70% in New Jersey to 82% in Utah. Suboptimal percentages had claims indicating recommended exams were performed. Of those receiving diabetes medication, 43% (5.6 million) had medical claims indicating poorly controlled diabetes-ranging from 29% with poor control in Minnesota and Iowa to 53% in Texas. Poor control was correlated with higher prevalence of neurological complications (+14%), renal complications (+14%), and peripheral vascular disease (+11%). Patients with poor control averaged $4,860 higher average annual health care expenditures-ranging from $6,680 for commercially insured patients to $4,360 for Medicaid and $3,430 for Medicare patients. This study highlights the large number of insured adults with undiagnosed type 2 diabetes by insurance type and state. Furthermore, this study sheds light on other gaps in diabetes care quality among patients with diagnosed diabetes and corresponding poorly controlled diabetes. These findings underscore the need for improvements in data collection and diabetes screening and management, along with policies that support these improvements.

Medicare Part D is a prescription drug program that provides seniors and disabled individuals enrolled in Medicare with outpatient drug coverage benefits. Part D has been shown to increase access to medicines and improve medication adherence; however, the effect of Part D on health outcomes has not yet been extensively studied. In this study, we used a published and validated Markov-based microsimulation model to quantify the relationships among medication use, disease incidence and severity, and mortality. Based on the simulation results, we estimate that since the implementation of Part D in 2006, nearly 200,000 Medicare beneficiaries have lived at least 1 year longer. Reductions in mortality have occurred because of fewer deaths associated with medication-sensitive conditions such as diabetes, congestive heart failure, stroke, and myocardial infarction. Improved access to medication through Medicare Part D helps patients improve blood pressure, cholesterol, and blood glucose levels, which in turn can prevent or delay the onset of disease and the incidence of adverse health events, thus reducing mortality.

OBJECTIVE To update estimates of the economic burden of undiagnosed diabetes, prediabetes, and gestational diabetes mellitus in 2012 in the U.S. and to present state-level estimates. Combined with published estimates for diagnosed diabetes, these statistics provide a detailed picture of the economic costs associated with elevated glucose levels. RESEARCH DESIGN AND METHODS This study estimated health care use and medical expenditures in excess of expected levels occurring in the absence of diabetes or prediabetes. Data sources that were analyzed include Optum medical claims for ∼4.9 million commercially insured patients who were continuously enrolled from 2010 to 2012, Medicare Standard Analytical Files containing medical claims for ∼2.6 million Medicare patients in 2011, and the 2010 Nationwide Inpatient Sample containing ∼7.8 million hospital discharge records. The indirect economic burden includes reduced labor force participation, missed workdays, and reduced productivity. State-level estimates reflect geographic variation in prevalence, risk factors, and prices. RESULTS The economic burden associated with diagnosed diabetes (all ages) and undiagnosed diabetes, gestational diabetes, and prediabetes (adults) exceeded $322 billion in 2012, consisting of $244 billion in excess medical costs and $78 billion in reduced productivity. Combined, this amounts to an economic burden exceeding $1,000 for each American in 2012. This national estimate is 48% higher than the $218 billion estimate for 2007. The burden per case averaged $10,970 for diagnosed diabetes, $5,800 for gestational diabetes, $4,030 for undiagnosed diabetes, and $510 for prediabetes. CONCLUSIONS These statistics underscore the importance of finding ways to reduce the burden of prediabetes and diabetes through prevention and treatment.