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Economic Burden of Diabetes
Building Perspective for the
Corporates Industrialists
Sanjeev Kelkar
Conjoint Faculty
The Uni...
Congratulations to Dr Kayathri!
Proud of a Colleague
Setting new rules for the old game
Empathy, Empowerment, Education
De...
Compared to Normal Population ---
A person with diabetes carries
17 times more risk for blindness,
more than 50% of all th...
Congratulations to Dr Kayathri!
Proud of a Colleague
Diabetes takes all this and more, that is
why and where the challenge...
And there are huge costs
Costs X numbers X number of
complications make staggering numbers
Let us have a look at it.
Economic Burden of Diabetes in India
Grateful Thanks to
Anil Kapur
Vice Chairman
World Diabetes Foundation
Copenhagen, Den...
Top Countries with Diabetes
Temporal Prevalence in Urban South India
5.0
8.2
11.6
14.2
R
2
= 0.9971
0
2
4
6
8
10
12
14
16
18
20
1988 1992 1996 2000
Ku...
Six Cities
National Urban Diabetes Survey
 
Total 11, 216 M : F 5288:5928
Prevalence %
N Crude Age-std n Crude Age-std
Tot...
National Urban Diabetes Survey
Diabetologia 44: 1094-1101;2001
Wild et al
Diabetes Care 2004; 27:1047-53.
Age Specific Pre...
Lifestyle in Transition
Diabetes Mellitus- Genetics
Risk of Diabetes
- F/H/O Diabetes
- One parent diabetic
- One parent diabetic and
other from a...
Demographics
Age Groups
0
25
50
<15 15-30 30-45 45-55 55-70 >70
Current Age Distribution
Mean Age at Onset of Diabetes 43....
Diabetes Complications
In Relation To Diabetes Duration
60%
35%
29%
64%
32%
19%12%
5% 4%4% 2% 2%2%
<5y5-10y>10y
Foot Eye M...
Persons with Diabetes Use Higher Health Care Resources
Rendell et al
Arch Intern Med 1993
%ofTotal
0
4
8
12
16
25-35 36-45...
CODE 2: Effect of complications on per patient costs
0
1
2
3
4
Costimpactfactor
None Microvascular Macrovascular Both
With...
Mean Expenditure Per Hospitalization (INR)
16565
9888
13200
7668
12781
0
2
4
6
8
10
12
14
16
18
Overall Type 1 Type 2 No C...
Proportion of Average Overall Costs –
CODE 2
Antidiabetic
drugs
7% Ambulatory
18%
Other drugs
21%
Hospitalisation
55%
Quality and Complexity of Care,
Costs for People Who Are Ill
DIABETES IS RISING HIGH AND
RIDING HIGH ON COMPLICATIONS
Why diabetes?
• Diabetes is the central paradigm of non
communicable diseases just as
• Tuberculosis is the central paradi...
Why diabetes?
• Diabetes control has inescapably got tied with
control of cholesterol and fats, Blood Pressure and
coronar...
Why Costs Go High?
• Delayed diagnosis – 5 to 7 years
• Up to 50% having some tissue damage at
diagnosis – UKPDS
• Team ap...
Why Costs Go High?
• Health Care Delivery Structure vis a vis
capability to deal with non communicable diseases, requires
...
Cost Effective High Quality Solutions
• Common sense, common place
restructuring / orientation of public health
care deliv...
Issues in SL
Evolving new roles
• between the central and the peripheral
areas during the transition period
• between the ...
Issues in SL
• For example, foreign donors eager to
upgrade the rural health care delivery
system have provided expensive
...
Glaring issues in SL
• Mismatch on expertise in the rural areas for
maintaining or running this equipment, it
remains unus...
Glaring issues
• Supply driven health care offers –
mismatch between the real need and
suitable measures answering them
• ...
Socio Economic Factors
• Lack of awareness in patients & doctors
• Population in rural area –
Law of inverse care applies
...
Costs of Managing Diabetes
• Regular monitoring of diabetes and its
complications
• Drugs, hospitalizations, surgeries,
• ...
Costs - rising in future
• In next 20 years costs of treatment will escalate; a
rising affluent class may foot it out of p...
Currently available financial supports
for diabetes
• Self expenditure
• Insurance
• Charity
• Public Sector Healthcare
• ...
Two Thirds of Healthcare Spending is out of Pocket,
0% 10% 20% 30% 40% 50% 60%
PP
PC/NC
OP
PHC
PHC : Public Clinic /Primar...
Social Health Insurance
WHO Study Group on "Evaluation of Recent
Changes in Financing of Health Services
concluded that "T...
Social Health Insurance
• The insurer excludes the very people
most in need of protection - the poor, the
elderly and the ...
Social Health Insurance – Model
• Prepayment or contribution. Payment is
made regularly irrespective of whether
services a...
Social Health Insurance – Model
• Most beneficial – universal contributions made
statutory.
• A financial source separate ...
Health Insurance / Schemes in India
Beneficiaries (in Million)
• State Insurance Scheme (ESIS) 25.3
• Health Insurance (pr...
Health Insurance / Schemes in India
Beneficiaries (in Million)
• Central Government 4.3
• Railways 8.0
• Defence Employees...
Proposed Financial Supports
• National Rural Health Mission – the
Community Health Center based
model
• Talks of public pr...
Health Insurance – Schemes Proposed
• Community based insurance schemes
Definable geographic locations
• Trade Based insur...
Health Insurance – Schemes
Proposed
• Third Party Administered schemes –
defined protocols,
expense limits for indoor care...
Health Insurance
• Limited Coverage, operative in only the
organized sector of economy
• The concern is the unorganized se...
Health Insurance
• Quality of services
• Purposes for which used - leave,
getting prescribed
• Final run off still to priv...
Create Public-Private Partnership.
Models
Options Successful Examples
Contract out Services Contract out non-clinical
hosp...
Components of current available financial
supports
• Charity – potentially a non self
fuelling way of solving health care
...
Prevention is the key
Scientific evidence of
studies in cost benefits of prevention
Costs & Benefits
• Potential economic benefits of lower-extremity
amputation prevention strategies in diabetes.
Ollendorf ...
Cost benefit in prevention
• Team approach toward lower extremity
amputation prevention in diabetes
• RG Frykberg
Harvard ...
Cost benefit in prevention
• Primary Prevention – Nice to talk about,
fashionable, unattainable,
• Establish a Gym for you...
Role Corporates Could Play
• As employers – Insurance, reimbursement,
promoting good practices,
• Discharging Corporate So...
THANK YOU
Industry & Insurance
• As employer sponsored insurance, the
cornerstone of US health Care
• Medical professionals employee...
Employer Offered Insurance
• Only 66.8% non elderly healthy working adults
covered
• Retirees getting much less covered
• ...
New Products from Insurance
• Aimed at cost containment
• Paying for performance (UK)
• Disease-management initiatives
• H...
New Products from Insurance
• New mechanisms focus on patient safety and
quality of care
• ie, more evidence based, more p...
Government Offered Insurance
• In industrialized countries health coverage
relates to tax revenues from businesses
• Varie...
Glaring issues
• Through a combination of foreign donor
ignorance of key features of Sri Lankan
health care delivery syste...
Glaring issues
• Ethical issues arising in a mixed health
care delivery – public and private
• Minimum obligatory health p...
• IS COMMUNITY DIABETES
WORKER A SOLUTION?
• Going back to the PHC profile with an
additional new task
• Separate cadre ar...
Currently Available Health Care
• Public Sector Health Care –
PHCs archaic, non evolving invariant
model,
• Huge task prof...
Analysing Glaring Issues
• Statistics on the use of private funds for
health care; a normative analysis of
private-public ...
Major Challenges
• The population is aging,
• Ageing population
• Non-communicable diseases in adults - diabetes 5% of SL
...
Components of current available financial
supports for amputation prevention
• Employer reimbursement – varies
with the he...
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1362574283 economic burden dm sl

  1. 1. Economic Burden of Diabetes Building Perspective for the Corporates Industrialists Sanjeev Kelkar Conjoint Faculty The University of Newcastle Australia
  2. 2. Congratulations to Dr Kayathri! Proud of a Colleague Setting new rules for the old game Empathy, Empowerment, Education Demystification, Helping patient take charge of his illness, putting him in driver’s seat to make decisions, support, take him as a partner in coping with diabetes
  3. 3. Compared to Normal Population --- A person with diabetes carries 17 times more risk for blindness, more than 50% of all those who are on dialysis, in ICUs, getting amputated in leg are due to diabetes carry a 4 times higher prevalence of hypertension
  4. 4. Congratulations to Dr Kayathri! Proud of a Colleague Diabetes takes all this and more, that is why and where the challenge lies, Each one is affected, each has to contribute, come together to contain the menace and the epidemic
  5. 5. And there are huge costs Costs X numbers X number of complications make staggering numbers Let us have a look at it.
  6. 6. Economic Burden of Diabetes in India Grateful Thanks to Anil Kapur Vice Chairman World Diabetes Foundation Copenhagen, Denmark
  7. 7. Top Countries with Diabetes
  8. 8. Temporal Prevalence in Urban South India 5.0 8.2 11.6 14.2 R 2 = 0.9971 0 2 4 6 8 10 12 14 16 18 20 1988 1992 1996 2000 Kudremukh Chennai Chennai Chennai Bangalore Hyderabad Ramachandran A et al
  9. 9. Six Cities National Urban Diabetes Survey   Total 11, 216 M : F 5288:5928 Prevalence % N Crude Age-std n Crude Age-std Total 1631 14.4 14.0 1684 13.9 12.1 Men 776 14.6 14.0 813 13.8 12.5 Women 855 14.3 14.1 871 14.0 11.9 IGT DM National Urban Diabetes Survey Diabetologia 44: 1094-1101;2001
  10. 10. National Urban Diabetes Survey Diabetologia 44: 1094-1101;2001 Wild et al Diabetes Care 2004; 27:1047-53. Age Specific Prevalence 2.3 7.6 17.9 27.7 31.1 27.2 11.6 14.3 15.5 14.8 16.6 20.2 0 5 10 15 20 25 30 35 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 >69 DM IGT Age groups (years) % India Global
  11. 11. Lifestyle in Transition
  12. 12. Diabetes Mellitus- Genetics Risk of Diabetes - F/H/O Diabetes - One parent diabetic - One parent diabetic and other from a diabetic family Family History 20 % 40 % 70 % V Mohan & KGMM AlbertiV Mohan & KGMM Alberti International Textbook of Diabetes Mellitus,1992,178.International Textbook of Diabetes Mellitus,1992,178. • Family history significant predictor of Diabetes
  13. 13. Demographics Age Groups 0 25 50 <15 15-30 30-45 45-55 55-70 >70 Current Age Distribution Mean Age at Onset of Diabetes 43.6 ± 12.2 (n= 2251) Mean Diabetes Duration 10.0 ± 6.9 (n= 2251)
  14. 14. Diabetes Complications In Relation To Diabetes Duration 60% 35% 29% 64% 32% 19%12% 5% 4%4% 2% 2%2% <5y5-10y>10y Foot Eye MI Stroke ESRD n=480n=626n=901
  15. 15. Persons with Diabetes Use Higher Health Care Resources Rendell et al Arch Intern Med 1993 %ofTotal 0 4 8 12 16 25-35 36-45 46-55 56-65 Age Group % of Total Population with Diabetes % of Total Charges Attributable to Diabetes
  16. 16. CODE 2: Effect of complications on per patient costs 0 1 2 3 4 Costimpactfactor None Microvascular Macrovascular Both Without complications With complications 1.7 X 2.0 X 3.5 X Lucioni C et al. PharmacoEconomics- Italian Research Articles, 2000 2(1):1-21 None Microvascular Macrovascular Both
  17. 17. Mean Expenditure Per Hospitalization (INR) 16565 9888 13200 7668 12781 0 2 4 6 8 10 12 14 16 18 Overall Type 1 Type 2 No Comp 3+ Comp CODI Study
  18. 18. Proportion of Average Overall Costs – CODE 2 Antidiabetic drugs 7% Ambulatory 18% Other drugs 21% Hospitalisation 55%
  19. 19. Quality and Complexity of Care, Costs for People Who Are Ill DIABETES IS RISING HIGH AND RIDING HIGH ON COMPLICATIONS
  20. 20. Why diabetes? • Diabetes is the central paradigm of non communicable diseases just as • Tuberculosis is the central paradigm of communicable diseases • If we improve quality of health care for both a large improvement in related health areas will occur
  21. 21. Why diabetes? • Diabetes control has inescapably got tied with control of cholesterol and fats, Blood Pressure and coronary heart disease, • Offers protection to retina, kidney and foot, lessens thereby the burden of cerebrovascular disease • Tuberculosis cannot be dealt with without important structure – function changes in the health care delivery system
  22. 22. Why Costs Go High? • Delayed diagnosis – 5 to 7 years • Up to 50% having some tissue damage at diagnosis – UKPDS • Team approach lacking, slack controls, • Graduate and post graduate curriculum inadequate in content and time • Multiple disciplines of medicine converge on diabetes
  23. 23. Why Costs Go High? • Health Care Delivery Structure vis a vis capability to deal with non communicable diseases, requires a different mind set • Spiral of upward pressure builds from the level of maximum number and limited quality at periphery • Strong referral channels between primary, secondary and tertiary care could mitigate the problem • Second level capabilities addressing 95% of illness at provincial level satisfactorily – the most crucial link is missing
  24. 24. Cost Effective High Quality Solutions • Common sense, common place restructuring / orientation of public health care delivery • Intelligent, non demotivating regulation of private sector, particularly on quality assurance and wastes of huge money
  25. 25. Issues in SL Evolving new roles • between the central and the peripheral areas during the transition period • between the private and the public sectors. These transitions result may cause • sub optimal utilization of funds, • affecting the internal distribution of resources, also foreign donations.
  26. 26. Issues in SL • For example, foreign donors eager to upgrade the rural health care delivery system have provided expensive equipment to rural hospitals • Operational systems do not improve • Functional efficiency does not improve
  27. 27. Glaring issues in SL • Mismatch on expertise in the rural areas for maintaining or running this equipment, it remains unused. • Prevalence of pertinent disorders vis a vis the capacity and standing expense of these equipment in rural areas
  28. 28. Glaring issues • Supply driven health care offers – mismatch between the real need and suitable measures answering them • A number of large health care projects, some of which are in the planning process, create waste which,
  29. 29. Socio Economic Factors • Lack of awareness in patients & doctors • Population in rural area – Law of inverse care applies 1. quality and poverty, 2. distance from the first competent care level, time to reach it in time • SL has a good track record at primary care level, could be strengthened
  30. 30. Costs of Managing Diabetes • Regular monitoring of diabetes and its complications • Drugs, hospitalizations, surgeries, • Foot problems – dressings, vascular surgery, rehabilitation after foot salvage surgery, loss of income, change in the job/employment
  31. 31. Costs - rising in future • In next 20 years costs of treatment will escalate; a rising affluent class may foot it out of pocket but • the majority will find it more and more difficult to meet it o o p • mechanism to meet costs has to be developed, one way is insurance • has benefits, may make adequate social impact in preventing debilitating complications
  32. 32. Currently available financial supports for diabetes • Self expenditure • Insurance • Charity • Public Sector Healthcare • Employer reimbursement
  33. 33. Two Thirds of Healthcare Spending is out of Pocket, 0% 10% 20% 30% 40% 50% 60% PP PC/NC OP PHC PHC : Public Clinic /Primary Health Care Centres OP : Other Private – includes both qualified and others PC/NC : private Clinic / nursing home PP : Private Practitioner Source: CII –McKinsey & Company, Healthcare In India: The Road Ahead, CII and McKinsey & Company, New Delhi, 2002, p. 38.
  34. 34. Social Health Insurance WHO Study Group on "Evaluation of Recent Changes in Financing of Health Services concluded that "There are no private health insurance markets at all. When they do exist, they are guilty of "Cream Skimming".
  35. 35. Social Health Insurance • The insurer excludes the very people most in need of protection - the poor, the elderly and the unhealthy". • Private health insurance is, therefore, not a viable option for healthcare financing in Sri Lanka.
  36. 36. Social Health Insurance – Model • Prepayment or contribution. Payment is made regularly irrespective of whether services are used or not; • Pooling of funds; • Cross-subsidizing; • Sharing of risks.
  37. 37. Social Health Insurance – Model • Most beneficial – universal contributions made statutory. • A financial source separate from general tax revenue, • Services supplied utilizing the existing infrastructure • Sufficient control vested in the ministry of health to safeguard the poor and to control cost escalation. ROHAN JAYASURIYA, Department of Public Health and Nutrition,University of Wollongong Australia
  38. 38. Health Insurance / Schemes in India Beneficiaries (in Million) • State Insurance Scheme (ESIS) 25.3 • Health Insurance (private sector non-life companies) 0.8 • Health Segment of Life Insurance Companies (public and private) 0.23 • State Sponsored Schemes<0.50 • Mining and Plantations (public sector) 4.0 • Health Insurance (public sector non-life companies) 10.0
  39. 39. Health Insurance / Schemes in India Beneficiaries (in Million) • Central Government 4.3 • Railways 8.0 • Defence Employees 6.6 • Ex-servicemen 7.5 • Employers run facilities/reimbursement private sector 6.0 • Employers run facilities/reimbursement public sector<8.0 • Community Health Scheme 3.0 • Total 85.0
  40. 40. Proposed Financial Supports • National Rural Health Mission – the Community Health Center based model • Talks of public private partnerships, of user fees • Under automatic criticism of left wing
  41. 41. Health Insurance – Schemes Proposed • Community based insurance schemes Definable geographic locations • Trade Based insurance, eg weavers, • Toying with Universal Health Insurance – part subsidy by the central government
  42. 42. Health Insurance – Schemes Proposed • Third Party Administered schemes – defined protocols, expense limits for indoor care, provider beneficiaries connected, cashless at the point of service, • Severs payment service connections, TPA decides on the exactitude of management • Mixed opinions on workability
  43. 43. Health Insurance • Limited Coverage, operative in only the organized sector of economy • The concern is the unorganized sector in a still dominantly agro based economy in SL • Majority Schemes do not cover preexisting diabetes, • Major Private health Insurance companies not active players
  44. 44. Health Insurance • Quality of services • Purposes for which used - leave, getting prescribed • Final run off still to privateers • Overall sub-optimality with islands of excellences
  45. 45. Create Public-Private Partnership. Models Options Successful Examples Contract out Services Contract out non-clinical hospital service (e.g., catering, laundry) Contract out clinical hospital services (e.g. radiology, pathology : : Karnataka: Cleaning, maintenance and waste management contracted out in 82 hospitals. Tamil Nadu: High technology services in major teaching hospitals contracted out. Private Management of Public Facilities Private management of primary facilities. Private management of public hospitals. : : Tamil Nadu: Management of PHCs by corporate houses with large presence in the area. Gujarat: PHCs in one district managed by SEWA. Source: CII –McKinsey & Company, Healthcare In India: The Road Ahead, CII and McKinsey & Company, New Delhi, 2002, p. 183.
  46. 46. Components of current available financial supports • Charity – potentially a non self fuelling way of solving health care issues • External funds, loans etc
  47. 47. Prevention is the key Scientific evidence of studies in cost benefits of prevention
  48. 48. Costs & Benefits • Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Ollendorf DA, Kotsanos JG, Wishner WJ, Friedman M, Cooper T, Bittoni M, Oster G. Policy Analysis Incorporated, Brookline, Massachusetts, USA. • The total potential economic benefits (discounted at 5%) of strategies to reduce amputation risk ranged from $2,900 to $4,442 per person with a history of foot ulcer over 3 years. • Benefits were highest for educational interventions. • Most benefits were found to accrue among individuals aged > or = 70 years.
  49. 49. Cost benefit in prevention • Team approach toward lower extremity amputation prevention in diabetes • RG Frykberg Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA. Cost of prevention are more likely to prevent higher costs of treatment among veterans.
  50. 50. Cost benefit in prevention • Primary Prevention – Nice to talk about, fashionable, unattainable, • Establish a Gym for your employees and measure the utilization • Industry may become a part of a nationwide campaign? • Well tested models available, electronic media underutilized
  51. 51. Role Corporates Could Play • As employers – Insurance, reimbursement, promoting good practices, • Discharging Corporate Social Responsibility, contributing skills, • Data generation on what exists and needs remedied • Adopting parts of HCDS, • Funding Health Campaignes
  52. 52. THANK YOU
  53. 53. Industry & Insurance • As employer sponsored insurance, the cornerstone of US health Care • Medical professionals employees of health care organizations of insurance companies • Part of pay packet, negotiable • Non Taxable as income to the workers • US$ 1180/- per covered employee, or $188.5 billion (NEJM, July 6th and 13th2006 Bloomenthal
  54. 54. Employer Offered Insurance • Only 66.8% non elderly healthy working adults covered • Retirees getting much less covered • Cost escalation to 16% GDP in 2004 in US • Balance between cash wages and benefits dependent on net profits of the business; gets linked to the fortune of private business • Finally Health Insurance passed on to the employees • Millions of working citizens uncovered • Political will could do better in US
  55. 55. New Products from Insurance • Aimed at cost containment • Paying for performance (UK) • Disease-management initiatives • Health saving accounts • Consumer directed health plan • Tiered payment systems
  56. 56. New Products from Insurance • New mechanisms focus on patient safety and quality of care • ie, more evidence based, more protocol based care • Still does not effectively lower costs across the board nor improve quality • Employers cannot innovate on health care practices, low, scattered numbers, change in leadership, sale, mergers, low success on coalitions among employers, lack of internal expertise,
  57. 57. Government Offered Insurance • In industrialized countries health coverage relates to tax revenues from businesses • Varies with the performance of the units • Other social mechanisms may come in
  58. 58. Glaring issues • Through a combination of foreign donor ignorance of key features of Sri Lankan health care delivery system • And a lack of public and accountable decision making procedures in Sri Lanka, have resulted in waste of foreign donations
  59. 59. Glaring issues • Ethical issues arising in a mixed health care delivery – public and private • Minimum obligatory health package the government is obliged to give • The role private sector (should) play(s) • Element of competition – User fees • Equitable health care delivery .
  60. 60. • IS COMMUNITY DIABETES WORKER A SOLUTION? • Going back to the PHC profile with an additional new task • Separate cadre arising out of NGOs, • Problems of self sustaining mechanism • Second level back up is a fundamental need grossly inadequately answered in Public Health System
  61. 61. Currently Available Health Care • Public Sector Health Care – PHCs archaic, non evolving invariant model, • Huge task profile vis a vis woefully limited capacity, Unmotivated, • Needs scrapping, out of tune with changing economic states of people, and disease management requirement • Lacks competent second level care back up
  62. 62. Analysing Glaring Issues • Statistics on the use of private funds for health care; a normative analysis of private-public provision of health care • Descriptive analysis of the problems of private-public interaction in health care;
  63. 63. Major Challenges • The population is aging, • Ageing population • Non-communicable diseases in adults - diabetes 5% of SL adult population; • Heart disease, cerebro-vascular disease 3 to 4 times more common than non diabetic population, • Burden of complications as already shown • Combined mortality of Diabetes and heart disease 24%, • (accidents, suicides, etc %, CVD %, Cancer %)
  64. 64. Components of current available financial supports for amputation prevention • Employer reimbursement – varies with the health of the business, has procedural / conceptual confusions, eg. nature of packages, choice of facility,

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