摘要：Objectives. We estimated national and state-level potential medical care cost savings achievable through modest reductions in the prevalence of several diseases associated with the same lifestyle-related risk factors. Methods. Using Medical Expenditure Panel Survey Household Component data (2003–2005), we estimated the effects on medical spending over time of reductions in the prevalence of diabetes, hypertension, and related conditions amenable to primary prevention by comparing simulated counterfactual morbidity and medical care expenditures to actual disease and expenditure patterns. We produced state-level estimates of spending by using multivariate reweighting techniques. Results. Nationally, we estimated that reducing diabetes and hypertension prevalence by 5% would save approximately $9 billion annually in the near term. With resulting reductions in comorbidities and selected related conditions, savings could rise to approximately $24.7 billion annually in the medium term. Returns were greatest in absolute terms for private payers, but greatest in percentage terms for public payers. State savings varied with demographic makeup and prevailing morbidity. Conclusions. Well-designed interventions that achieve improvements in lifestyle-related risk factors could result in sufficient savings in the short and medium term to substantially offset intervention costs. The recent health care reform debate has heightened interest in the potential for national medical cost savings from investment in public health and disease prevention. National-level estimates are informative about the expected magnitude and distribution of returns to such investment across the various payers in the health care system. However, neither the magnitude nor the distribution of returns is likely to be uniform across states. Age, household income, and race/ethnicity are important correlates of the overall disease burden, and variation in the proportions of the population that are elderly, poor, and employed affect the distribution of cost burdens among payers. Because state governments likely will bear a significant portion of the investment costs, the states will benefit from savings estimates that take into account differences in the relevant demographic and economic characteristics affecting potential returns. Estimates of potential medical cost savings can provide guidance to states and other stakeholders on the extent to which outlays for prevention programs may be offset by reduced medical care spending. Because many chronic conditions stem from similar, largely lifestyle-related risk factors, such as smoking, poor diet, or inadequate physical activity, primary prevention programs aimed at addressing these causes have the potential to affect multiple conditions. 1 Research suggests that even small increases in exercise, improvements in nutrition, and continued reduction in tobacco use can have measurable effects on disease. 2 – 5 Risk factor reduction is likely to yield some savings in the short run by reducing the onset of uncomplicated disease, but the largest savings are likely to occur in the medium and longer runs because costly complications are avoided. The long-term horizon may reduce incentives for investment in primary prevention, particularly in the private sector where the original investor may expect to realize only some of the long-run return on investment. For example, few Americans have a single health insurer throughout their preretirement years, and Medicare becomes the primary payer for almost all US residents at the age of 65 years. Thus, much of the return on an insurer's investment in primary prevention for younger subscribers may accrue to other payers, particularly Medicare. Because the prevalence of chronic disease rises with age, the implications of failing to address modifiable risks at younger ages are higher costs for private insurers and Medicaid for the working-age population in the short run and greater Medicare costs to treat related advanced disease in the longer run. The challenge for public policy is to recognize and fully account for the incidence of both costs and savings over time in assessing the potential for savings from investment in primary prevention. For our study, we analyzed the excess medical costs associated with 2 common and preventable chronic diseases and the savings that could be realized over time from reductions in the prevalence of these 2 conditions and associated complications. Specifically, we modeled a reduction in the incidence of diabetes and hypertension, which was assumed to be accomplished through diet, exercise, and reduced smoking, and which, over time, would in turn reduce the incidence of some of the most serious and expensive complications of the 2 conditions—such as heart disease, stroke, and kidney disease—and their biological antecedents. We assumed that population-based primary prevention activities lead to reduced disease onset in the short run and, consequently, to reduced complications associated with the avoided diseases and their biological antecedents in the medium run. The assumption of population-based prevention means that intervention costs are not borne by the medical care system. We estimated potential savings at both the state and national levels from a model that took state differences into account.
