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Diagnosis Diabetes:
Longer Lives,
Higher Costs

Recent developments in the fight against diabetes provide hopeful signs. The rate of new diabetes cases (here including both Type I and Type II) is stabilizing. And for people with diabetes, the disease is not as deadly as it once was.

However, this progress comes at a high cost. Seniors with diabetes tend to have much more expensive healthcare needs than younger diabetics. And because people with diabetes are now living much longer, the overall cost of treating diabetes is skyrocketing. As diabetes prevalence and treatment cost become concentrated more and more among elderly Americans, Medicare will need to foot an outsize portion of the bill.

About the Author
Jeroen van Meijgaard, PhD, is a researcher at the UCLA Fielding School of Public Health.

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Diabetes Prevalence and Incidence

To evaluate trends in diabetes, it is useful to look at the prevalence of the disease—that is the percent of the population that has diabetes. Every year, the Centers for Disease Control and Prevention (CDC) surveys people across the country to gain a better understanding of people’s health and wellbeing, including how disease impacts the country. The findings related to diabetes are made available by the CDC's Division of Diabetes Translation.

Diabetes prevalence started rising rapidly during the 1990s. In the early 1990s, about 4 percent of the adult population had diabetes. This figure doubled to 8% in just about 10 years. Although the increase has been slower in recent years, the prevalence is now almost 10% of the adult population.

Prevalence statistics are vital, but they do not tell the whole story alone. A related metric, diabetes incidence, tells us the number of new cases of diabetes.

Incidence is estimated by the CDC by asking participants in the National Health Interview Survey (NHIS) if they were diagnosed with diabetes in the year prior to the interview. (NHIS is conducted annually.)

Diabetes incidence in the United States rose steadily during the 1990’s and 2000’s, hitting a peak of 8.7 new cases per 1,000 people in 2008. Since then, it has declined. In 2015, there were 6.7 new cases per 1,000—still significantly higher than the rate in 1990, and with some caveats about the nature of its decline, but a hopeful sign nonetheless.

Diabetes Incidence and Prevalence
Crude rate per 1,000 adults (18 and older)
Source: US Diabetes Surveillance System; www.cdc.gov/diabetes/data; Division of Diabetes Translation - Centers for Disease Control and Prevention.

The incidence rate alone does not drive prevalence figures. In fact, while the diabetes incidence has stabilized or declined, prevalence has continued to rise. Prevalence may also increase independently of incidence if people who already have a disease live longer with it. The mortality data for diabetes shows this is precisely what is happening.

The Death Toll of Diabetes

Mortality statistics are compiled by the CDC, based on the death certificates that are submitted to local departments of vital statistics around the country. When a person dies, a doctor notes on the death certificate what he or she thinks to be the primary or underlying cause of death. The doctor also notes any additional conditions that may have contributed to death. These statistics are reported to the CDC as the Underlying Cause of Death (UCD) and Multiple Causes of Death (MCD), respectively. 

With a disease like diabetes, UCD statistics may understate the disease’s true impact, since it is often difficult to determine if the condition led to the death of the individual. Diabetes increases the risk of death of other disease—for example, cardiovascular disease—but it is not the only risk factor for those conditions. By evaluating the MCD statistics, we are more likely to capture most of the deaths where diabetes was a contributing factor.

Diabetes as a Contributing Cause of Death

Drag the time-slider to display data for different years.
Source: CDC Wonder. Multiple Cause of Death: Diabetes mellitus [E10–E14]

Diabetes-related mortality has stayed remarkably stable between 1999 and 2015, while the age-adjusted diabetes related mortality has declined somewhat from 76.7 per 100,000 in 1999 to 67.7 per 100,000 in 2015—even though the number of people with diabetes has increased dramatically.

To appreciate the decline in diabetes-related mortality, we can calculate the diabetes case mortality rate, the number of deaths where diabetes was a contributing factor versus the number of diabetics in a given year. This rate reflects the annual risk of dying from diabetes if you are a diabetic.

This risk has declined sharply especially for people over 65 as reflected in the chart. This decline is consistent with research that shows that the added mortality risk of diabetes has declined.

If the case mortality rate for diabetes is declining, we can conclude that people are living longer with diabetes. This is born out by data from the CDC, based on surveys where people are asked how long ago they were diagnosed with diabetes.

The fact that higher diabetes prevalence trends are now being driven by longer lifespans, rather than new cases, is an unqualified victory for public health. But this victory comes with a high price tag—particularly for older Americans. 

Diabetes Case Mortality:
Diabetes mortality (as contributing cause) per 1,000 diabetics
Figures computed from Mortality data (CDC Wonder) and Prevalence data (US Diabetes Surveillance System, Division of Diabetes Translation).

Lifetime Costs of Diabetes Care

Diabetes is a chronic condition requiring constant management. In its most advanced state, diabetes may lead to kidney failure, requiring expensive dialysis treatment or a kidney transplant. Diabetes may also lead to other serious complications, such as peripheral nerve damage and eye disease. These complications drive up costs of treatment for diabetic patients. Fortunately, early diagnosis and disease management have helped reduce the risk of complications from diabetes, reducing the associated medical costs.

However, managing the disease requires frequent checkups, monitoring and medications, shifting costs but not necessarily reducing them. The medical expenses for a diabetic patient are, on average, more than twice as those of a non-diabetic patient. The cost attributed to diabetes is also significantly higher for the elderly, and increases over time.

In the latest published cost estimates (2012), the American Diabetes Association estimated that the annual health care expenditures attributable to diabetes was $7,888 per diabetes patient. With patients living longer, the lifetime expenditures attributable to diabetes easily exceed $100,000 per diabetic. Expenditures increase as patients get older, and the total time living with diabetes is a big factor.

With improvements in the quality of diabetes care, patients live longer and enjoy healthier lives. As patients require treatment for longer, total medical expenses attributed to diabetes over the patients’ lives is increasing even faster.

Mean Years Lived with Diabetes
Source: US Diabetes Surveillance System; www.cdc.gov/diabetes/data; Division of Diabetes Translation - Centers for Disease Control and Prevention.

Diabetes Cost Calculator

This chart calculates the lifetime cost of diabetes, based on the patient's age of onset and death.

Source: Annual cost estimates based on American Diabetes Association, Economic Costs of Diabetes in the U.S. in 2007, Diabetes Care 31(3), and Economic Costs of Diabetes in the U.S. in 2012, Diabetes Care 36(4).
Lifetime Costs ($) Attributed to Diabetes

A Two-Front Battle to Contain Cost

Even without accounting for longer diabetic lifespans, demographic reality portends a looming cost crunch for Medicare, which provides health care for elderly Americans. In 2017, there were roughly 51 million Americans over 65 years old. With the aging of the baby boomer generation, by 2030, the Census Bureau projects that figure will rise to 73 million.

In 2017, Medicare spent approximately $100 billion on diabetes-attributable medical costs for covered individuals over 65 years old. By 2030, based on demographics alone, that figure will rise to roughly $142 billion (in 2017 dollars). With people living longer with diabetes, and rising prevalence among the elderly, that figure is expected to be substantially larger. 

Extended longevity, combined with higher cost of treatment for the elderly, will further drive up lifetime medical cost for each additional diabetes patient. This pattern changes the cost-benefit trade-off to focusing efforts on preventing new diabetes case. Not only are existing diabetics driving higher health care cost—each new incidence of diabetes presents a much higher cost of lifetime care than earlier generations of diabetics.

A large percentage of the population is pre-diabetic, having elevated blood sugars, but not high enough to be diagnosed as diabetic. Early detection of pre-diabetes through screening can help patients make the necessary changes to their lifestyle and behavior to avoid becoming diabetic. 

Health departments typically have limited resources, but will nevertheless need to step up efforts to prevent the progression from pre-diabetes to diabetes in the population—while simultaneously addressing the increased cost of treatment of the existing diabetes population.

References

American Diabetes Association (2008). Economic Costs of Diabetes in the U.S. in 2007, Diabetes Care 31(3): 596-615

American Diabetes Association (2013). Economic Costs of Diabetes in the U.S. in 2012, Diabetes Care 36(4): 1033-1046

Gregg EW, Cheng YJ, Saydah S, Cowie, C, Garfield, S, Geiss L, and Barker L (2012). Trends in Death Rates Among U.S. Adults With and Without Diabetes Between 1997 and 2006, Diabetes Care 35(6): 1252-1257

Selvin E, and Ali MK (2017). Declines in the Incidence of Diabetes in the U.S. - Real Progress or Artifact, Diabetes Care 40(9): 1139-1143

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