Counting all the costs: the economic costs of comorbidities

Counting all the costs: the economic costs of comorbidities David McDaid and A-La Park LSE Health & Social Care, London School of Economics and Political Science E-mail: d.mcdaid@lse.ac.uk European Parliament Interest Group on Mental Health, Wellbeing and Brain Disorders, December 2012

Structure Why is it important to consider the economic impact of co-morbidity What do we already know about the impact of comorbidity? Modelling the economic impact of co-morbidity in Europe? What are the potential policy consequences?

What do we know about the economic impacts of comorbidity?

Impact People with severe mental health problems have worse physical health and life expectancy than the general population. Two way relationship quite a lot of material on association Literature from outside Europe on some aspects of economic impact But remarkably little European literature on the costs of avoidable physical comorbidity

Impact Australia: psychological distress and obesity 33% increased risk of absenteeism 2-5 times increase in presenteeism with co-morbidity (Holden et al 2011) Schizophrenia: In US overall healthcare costs four times greater with physical comorbidity (McDonald et al 2005) Bipolar: Analysis of healthcare utilisation of 13,000 low income people with bipolar disorder in seven US states reported that comorbid conditions accounted for 70% of total health care expenditure (Guo et al 2008) Health care costs over a six month period were found to be between 50% and 75% higher in people with major depression and diabetes than in people without depression (Simon et al 2005)

Impacts on chronic disease management Welch et al 2009

Impacts on chronic disease management In Long Term Conditions and Mental Health - Naylor, Parsonage, McDaid et al 2012

Overlap between long term conditions and mental health problems In Long Term Conditions and Mental Health - Naylor, Parsonage, McDaid et al 2012

Differences in absence from work between diabetic patients with mental comorbidity and those without Hutter, Schnurr & Baumeister Diabetologia, 2010

Strengthening the evidence base in Europe

Economic modelling Objectives: To estimate the additional costs to the health care system and society of common physical health problems in people with mental health problems. Focus only on additional costs of type II diabetes and all cardiovascular disease Does not include direct costs of poor mental health Costs estimated for all EU-27 countries in 2010 Looking at individuals with three different mental health problems: schizophrenia, bipolar disorder

Economic modelling Design: Simulation modelling synthesising data on risk of comorbidity and costs to health/other sectors. Prevalence based costing approach All EU-27 countries Model parameters identified from literature review including: Increase in risk of diabetes and cardiovascular disease in each Member State Cost for all of the adult population (15+) living with comorbidity Country specific costs of diabetes and cardiovascular care Productivity losses due to work absenteeism, premature death and need for family care

Results (1) Conservatively poor mental health associated with additional 2.33 million cases of Type II diabetes (T2D) and 2.36 million cases of cardiovascular disease (CVD) in the EU. Annual costs to EU health care systems of dealing with excess cases of (T2D) diabetes and CVD estimated at 11.2 & 5.2 billion (2010 prices). Costs of lost productivity due to morbidity, premature mortality and need for informal care estimated to be 10.6 (T2D) & 4.5 (CVD) billion per annum. But not all productivity losses are avoidable as will still be productivity losses associated with poor mental health.

Results (2) Conservatively poor mental health associated with additional 3.39 million cases of Type II diabetes (T2D) and 2.36 million cases of cardiovascular disease (CVD) in the EU. Germany accounts for 33% of overall costs of diabetes and 29% of CVD due to a combination of high underlying rates of chronic disease in the population and relatively high health care and productivity costs in the EU. Productivity losses higher than health care costs in some countries due to combination of low costs/investment in diabetes and CVD care plus greater reliance on family members.

Excess Diabetes Costs in Countries Country Diabetes Health Care Costs ( billions) Diabetes Productivity Losses ( billions) Germany 3.15 3.69 6.84 France 2.07 1.25 3.32 Italy 1.51 1.45 2.96 UK 1.02 1.22 2.24 Spain 0.89 0.82 1.70 Total Diabetes Cost ( billions)

Excess CVD Costs in Countries Country CVD Health Care Costs ( billions) CVD Productivity Losses ( billions) Germany 1.54 1.39 2.92 Italy 0.81 0.51 1.32 UK 0.50 0.59 1.08 France 0.66 0.40 1.06 Spain 0.41 0.37 0.78 Total CVD Costs ( billions)

1.400.000 Excess cases of Type 2 diabetes and CVD in people with mental health problems in the EU-27 2010 1.200.000 1.000.000 800.000 600.000 Diabetes CVD 400.000 200.000 0 Men Schizophrenia Women Schizophrenia Men Bipolar Women Bipolar Men Depression Women Depression

millions Annual Excess Health System of Costs of T2D and CVD in people with mental health problems in the EU 2010 8.000 7.000 6.000 5.000 4.000 Diabetes CVD 3.000 2.000 1.000 0 Schizophrenia Bipolar Disorder Major Depression

millions Productivity losses from excess T2D and CVD in people with mental health problems in 2010 8.000 7.000 6.000 5.000 4.000 Diabetes CVD 3.000 2.000 1.000 0 Schizophrenia Bipolar Disorder Major Depression

millions 600 Societal cost of higher rate of diabetes in people with schizophrenia in 2010 500 400 300 200 Men - health diabetes Men - productivity diabetes Women - health diabetes Women - productivity diabetes 100 0

millions Excess Costs of Diabetes in People with Bipolar Disorder in the EU- 27 in 2010 250 200 150 100 Men - health diabetes Men - productivity diabetes Women - health diabetes Women - productivity diabetes 50 0

millions 1.400 Excess costs of diabetes in people with major depression in the EU 2010 1.200 1.000 800 600 Men - health diabetes Men - productivity diabetes Women - health diabetes Women - productivity diabetes 400 200 0

millions 180 Excess costs of CVD in people with schizophrenia in the EU 2010 160 140 120 100 80 60 Men - health CVD Men - productivity CVD Women - health CVD Women - productivity CVD 40 20 0

millions 120 Excess cost of CVD in people with bipolar disorder in the EU in 2010 100 80 60 40 Men - health CVD Men - productivity CVD Women - health CVD Women - productivity CVD 20 0

millions 600 Excess cost of CVD in people with major depression in the EU in 2010 500 400 300 200 Men - health CVD Men - productivity CVD Women - health CVD Women - productivity CVD 100 0

Potential economic benefits of risk reduction We looked at the potential economic benefits of achieving a modest 1% reduction in excess risk of diabetes and CVD across the EU. This could avoid costs of circa 628 million. Diabetes ( s millions) CVD ( s millions) Total Costs Avoided ( s millions) Schizophrenia 79 37 116 Bipolar 40 29 69 Depression 228 205 433

To sum up Conservative analysis: costs of physical illness in people with poor mental health greater than population average. Limited epidemiological data in many EU countries prevalence of comorbidity may be higher. But economic impacts affect women as much as men Major depression associated with highest total level of costs; schizophrenia associated with higher costs per case due to much higher risk of physical health problems Key Role of primary care & public health; better co-ordination of mental and physical health care Potential for cost effective actions; need for careful evaluation of effective and cost effectiveness of strategies