The Compression of Morbidity: Where We Stand 35 Years Later

AUGUST 19, 2014
Troy K. Trygstad, PharmD, PhD, MBA

Pharmacists can play an important role in the reduction of disability through patient-centered care.

The economic importance of the compression of morbidity theory introduced by Dr. James F. Fries three-and-a-half decades ago is profound. Fully one-fifth of the United States population will be 65 years or older by 2030. This is a near doubling of the fraction of the population that had achieved that aging milestone in the previous 2 decades.1 We are in the midst of the most significant shift toward population-level advanced aging in the history of the country, and arguably in the history of the world.

Consider this: if the US population’s average age increases even a single day, without a subsequent population-level compression of morbidity by an equivalent day, the resulting state of disability is increased for many millions of Americans. Disability dramatically reduces quality of life for patients as well as their caregivers. Disability is also extremely expensive. The average elderly or disabled person using Medicaid or Medicare as his or her payer (dually eligible) will incur more than $30,000 per year in health care costs.2 Moreover, the actual cost to the system tends to be greater than that amount since Medicaid and Medicare typically reimburse much less to providers than nongovernmental payers. More risk in the citizenry is spread over fewer healthy, younger citizens.

Without successful compression, we will find ourselves in a state of global noncompetitiveness. As discussed in earlier supplements in the Directions in PharmacyTM series, the rise in proportion of gross domestic product (GDP) spent on health care is unsustainable. The “health care versus butter” phenomenon (choosing other goods and services over health care when sensitive to pricing) becomes stronger and stronger as health care spending nears 20% of GDP, and will only be amplified by the proliferation of high-deductible plans resulting from a confluence of pressures of premium inflation, the growth of the individual plan market, and the imposition of the “Cadillac tax.” The combined effect of a less healthy population and a low-value delivery system in a global marketplace could be devastating over the next 2 decades for both US employers as well as US taxpayers.

The compression of morbidity calls for a broader, more inclusive, and more longitudinal approach to medical care delivery. Traditionally, the medical system has been geared toward “sick care” on the “now horizon.” The mantra has been “come see us when you are sick, only when you like, and only about the maladies that are outwardly present.” For successful compression of morbidity, the system must reorient to “see us early, see us often, and see us for conditions that won’t ultimately affect you outwardly for years to come. And, oh, by the way, let’s talk about wellness, not just disease mitigation.”

We are seeing a slow, albeit steady, movement toward “patient-centeredness” and away from product and “service-centeredness.” Compression occurs, or doesn’t occur, as a result of patient choices in relation to the medical and nonmedical environment around them. Exercise, eating healthy meals, avoiding stressful life habits, and yes, medication adherence, are all ultimately determined by patient behavior. But these occur through multiple vectors such as access to healthy food, safe places to exercise, and medications; ill-coordinated and suboptimal drug regimens causing discomfort; belief systems; and behavioral health status.

The medication adherence movement is arguably the most significant indicator of this emergence of the movement to compress morbidity that has occurred to date within the medical construct—and the movement is here to stay. It gained popularity within health services research circles through the late 1990s and in the earlier part of this century to the point where over 60,000 publications now exist in the area of patient nonadherence to medications.3 But it wasn’t until the later part of the last decade that it gained widespread popularity as a movement in the mainstream, owed in part to the New England Healthcare Institute’s finding of $290 billion in unrealized gains in health care cost avoidance resulting from patient nonadherence.4

The medication adherence movement has all of the traits of a patient-centered model of care delivery with an extended time horizon to compress morbidity. To date, the most similar movement to this effect has been widespread adoption of vaccination programs, which are also quite relevant to pharmacy practice.