Correction
An astute reader in New York contacted my office to question a statement I made in my March 31, 2005, column (“The Dynamic Hockey Stick”) about saving health care costs by delaying the onset of chronic illness. I wrote: “We have heard time and again that more than 50 percent of an individual's lifetime health care costs occur during the last six months of life.”
That is not correct, and I should have caught it. According to an article that appeared in the June 2004 issue of Health Services Research, “Nearly one-third of lifetime [health care] expenditures is incurred during middle age, and nearly half during the senior years.”
In addition, the article points out that for those who live to age 85, more than one-third of their lifetime expenditures will accrue in their remaining years.
My thanks to my careful readers for keeping me on my toes!
–Bill Brody
Recently, I heard someone exclaim that the predicted Social Security crisis will never actually occur. The reason, goes this armchair analysis, is simple: The epidemic of obesity, combined with the resurgence of smoking among our youth, will preclude many from ever reaching retirement age.
This brings a curious question to mind. We have heard time and again that more than 50 percent of an individual's lifetime health care costs occur during the last six months of life. Will the budget bureaucrats in the health care establishment someday conclude we're better off allowing people to smoke and overeat so that the young die faster? After all, when health care decisions are made purely on the basis of cost efficiency, it is best for individuals to be healthy most of their life and then to have a single, fatal heart attack. The alternative to sudden cardiac death is to help someone during the initial acute ischemic event, but then the person develops a chronic disease—congestive heart failure—which is one of the most costly diseases among Medicare recipients.
Another way of stating the question: Are all of the things we're doing with medicine and public health to reduce premature mortality actually going to increase lifetime health care costs by converting acute illnesses into chronic diseases? By neglecting to take into consideration other economic and noneconomic factors—such as quality of life and contribution to GDP by working adults—do we fail to make the most efficient choices in controlling overall health care costs for society?
I recently met with distinguished Hopkins medical alum James Fries, currently professor of medicine at Stanford. He has demonstrated that the most efficient interventions are those that delay the onset of morbidity of chronic diseases. In other words, allowing people to smoke and contract lung cancer with a likely premature death is more costly than spending money to reduce smoking and letting these individuals die at a later age from some other causative factor. Most medical and public health interventions, according to a landmark article published by Fries in 1980,* don't prolong maximum life expectancy, they advance the age at which chronic illness occurs and/or they prevent premature death. And in so doing, they effectively reduce overall health care costs.
The age of onset of chronic illness can be significantly influenced by a number of factors, including lifestyle choices (dietary and weight control, smoking cessation and exercise) and medical therapy (lipid reduction, treatment of hypertension), and hence onset of senescence may be delayed, even if lifespan is not increased appreciably.
Think of the graph of health care costs over time as a “dynamic hockey stick” in which the inflection point where costs begin to rise rapidly is linked to the onset of some acute or chronic illness. By delaying the time at which that inflection point occurs, when life expectancy remains approximately the same, the area under the curve is minimized, and so are costs.
Medicare costs (along with total U.S. health care costs) are rising rapidly. Some analysts have indicated that the rise is primarily related to the increased number of Medicare recipients, not necessarily to their age and health status. Such an observation, if correct, would be in concert with Fries' hypothesis that delaying onset of chronic illness is an effective means to controlling health care costs.
I realize that I am treading on thin ice, as far as my expertise goes in this area—and some of my readers will no doubt point out flaws in this simplistic analysis (and please do write to me with your feedback). Nonetheless, this way of looking at health care costs is a new construct for me, and I find it worthwhile to think about its implications, as we are going to be faced over the next half-century with questions about how to allocate efficiently the funds for providing health care to an aging population.
And since the NHL is no longer playing hockey, maybe we can use our new dynamic hockey stick to shoot the puck into the goal of lowering health care costs.
*Aging, Natural Death, and the Compression of Morbidity. James F. Fries, New England Journal of Medicine 303:130-135, July 17, 1980. 
