On November 6, 2019, the Academy for Eating Disorders (“AED”) in conjunction with the Strategic Training Initiative for the Prevention of Eating Disorders: A Public Health Incubator (“STRIPED”) a research and training program based at the Harvard T.H. Chan School of Public Health and Boston Children’s Hospital, announced that they were collaborating with economic consulting giant Deloitte Access Economics to develop the most comprehensive report to date on the social and economic costs of eating disorders in the United States.
On Wednesday, June 24, 2020, the US Deloitte Report was released. A copy of the Report is embedded here:
The Deloitte Report is a ninety-one (91) page document. It is broken into seven (7) distinct sections:
- Case Studies
- Financial Costs
- Loss of Well Being
- Best Practices
The Report includes ten (10) separate charts and forty-six (46) different tables. In short, the Report is designed to provide an extensive breakdown and analysis of the social and economic costs of eating disorders in the United States.
Because of its length, this article will attempt to succinctly highlight the important aspects of relevant sections. Note that the Report is statistic intensive and requires careful consideration and analysis.
[The language provided below under each section is largely pulled verbatim from the Report.]
The Background section identifies the types of eating disorders studied. It then explained the cost analysis of eating disorders (“EDs”) were estimated from a societal perspective for the fiscal year between October 1, 2018 and 30 September 30, 2019 (referred to as “2018-19” in the report) using cost-of illness methods.
Costs were then estimated using a prevalence approach, where prevalence was estimated based on a combination of nationally representative surveys and modelling studies in the US. Costs were then primarily generated by multiplying prevalence by mean incremental costs for people with EDs across a range of cost components, which included:
- financial costs to the health system (e.g. costs of providing care in hospital and residential treatment facilities, and visits to primary care provider and other health services).
- productivity costs from reduced workforce participation and reduced productivity at work, loss of future earnings due to premature mortality, and the value of informal care (lost productive income of caregivers who provide help to people with EDs).
- other costs, which include transfer costs, and their associated efficiency losses, or reduced economic efficiency, associated with the need to levy additional taxation to fund the provision of government services.
Prevalence and Mortality
Based on current lifetime prevalence, incidence and mortality data, the Report estimated that 28.8 million Americans alive in 2018-19 will have an ED at some point during their life – either in the past, present or future.
The Report states that the overall one-year prevalence of EDs was estimated to be 5.48 million cases. Prevalence was estimated to be higher in females 4.39 million cases compared to males 1.09 million cases. (approximately 80% females, 20% males)
It was estimated that 21.0 million people in 2018-19 have had an ED at some point in their lives, of which 14.4 million cases occurred in women and 6.6 million cases occurred in men. The overall lifetime prevalence of EDs was estimated to be 8.60% among females and 4.07% among males.
Evidence cited in the Report suggests that EDs are associated with substantial excess premature mortality. An authoritative meta-analysis found that mortality rates were 5.86 times higher than the general population in people with anorexia, 1.93 for bulimia, and 1.92 for eating disorder not otherwise specified (EDNOS). When these rates were extrapolated in the Report, it was estimated that approximately 10,200 deaths (ranging between 5,500 and 22,000 deaths) were associated with EDs in 2018-19.
This equates to approximately one death every 52 minutes. And yet, it must be noted that this mortality rate is estimated and includes deaths believed to be associated with ED conditions, NOT directly caused by ED.
Financial Costs and Well Being
The total financial costs associated with EDs were estimated to be $64.7 billion in 2018-19, which equates to $11,808 per person with an ED. In addition, EDs are also associated with a substantial reduction in well being among people with EDs, which resulted in a further (non-financial) value of $326.5 billion.
Of total financial costs ($64.7 billion), health system costs made up 7.0% of the total, accounting for $4.6 billion. Of this expenditure, $363.5 million was paid by Americans in out-of-pocket costs to manage their ED.
Productivity costs make up the largest share of total financial costs (75.2%) while efficiency losses account for 7.4%. Informal care, which is care given free of charge, accounted for the remaining 10.4% of financial costs attributed to EDs in 2018-19 (measured as the caregivers’ forgone labor earnings).
It was estimated that government bore 27.5% of total financial costs, with the remaining costs shared across individuals (29.0%), employers (25.2%), society and other payers (11.0%), and family or friends (7.3%).
Cost Effectiveness of Best Practice Intervention and Prevention
Another primary focus of the Report was to summarize evidence pertaining to the cost-effectiveness of stepped care and integrated care models, which the Report asserts are recognized as best practice in the care of people with EDs.
Stepped care is an evidence-based, staged system comprising a hierarchy of interventions, from the least to the most intensive, meaning that treatment is available to meet an individual’s needs at the point in time that they require the treatment.
Integrated care is characterized by the comprehensive delivery of health services, designed according to the multidimensional needs of the population and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care.
As the Report notes, often, there is little distinction between stepped and integrated care models in the evidence base. However, stepped and integrated care have been separately discussed in the Report as they can involve different care settings – for example, stepped care for an individual may include residential care following by an intensive outpatient (IOP) program, while a program delivered solely in an outpatient setting could still be integrated care.
The Report acknowledges there is limited literature evaluating the cost-effectiveness of the stepped and integrated models of care. Outcomes have been shown to improve with stepped care treatment compared to CBT alone (although it is recognized that CBT is often delivered as a treatment within the context of stepped care), and the time burden upon caregivers diminished substantially.
The incremental cost-effectiveness ratio (ICER) was $12,146 per person who abstained from BN behaviors for stepped care and $20,317 for CBT, suggesting that stepped care may be superior to single step interventions delivered in isolation.
The integrated care model is likely to provide cost-effective treatment by better offering multiple disciplines (e.g. medicine, nutrition, psychology/social work and psychiatry) to support a patient’s individual needs and their symptoms.
Partial hospitalization programs (PHPs) may also offer significant cost savings compared to inpatient care.
Unfortunately, the Report did not address proactive, prevention strategies and the amount of revenue that would be saved or recaptured by investing in those strategies instead of paying for reactive, treatment costs on the back end. This omission is both curious and glaring since the 2012 Australian Report estimated that for every $1 spent in proactive, preventive care, it saved approximately $4 on reactive treatment care on the back end.
Necessary Research Identified
The Report identified four (4) areas of research which are crucially needed to expand our understanding of eating disorders:
Research to estimate the cost-effectiveness of stepped, integrated care models to reduce the burden of ED in the United States and this research should be undertaken as a priority;
Research to determine the long term impacts of eating disorders and the impact of co-morbidities on the costs associated with eating disorders;
Research to estimate the costs that may be prevented through early intervention and prevention of eating disorders;
Research to understand and estimate the additional costs of eating disorders that may be attributable to structural racism and other structural oppressions in the US.
it should be noted that no lobbyists or eating disorder organizations are currently pursuing any bills which would provide funding for any of these areas of research.
Application in the Industry
The Report is an expansive report and is deserving of careful analysis and research to determine what applicability, if any, it may have to medical providers, mental health providers, insurance benefit providers, large corporations and governmental entities. Potentially, its application and use in the United States could be invaluable. At the same time, some glaring omissions in the Report could undermine its usefulness.
The Report could be the foundation upon which eating disorder bills in the nation’s capital and in state capitals could be based. Long abandoned bills which once emphasized research could be resurrected since they would now be supported by objective, third party information, statistics and facts. Research exploring that aggressive, preventive, proactive measures with possible pharmacological involvement could be pursued. Or, the Report could be lost in the ocean of white noise which seems to define the eating disorder industry.
How will the Report be utilized?
During the seven season run of the television series, “The West Wing,” the fictional character, President Josiah Bartlet [played by Martin Sheen] repeatedly asked his White House staff, “What’s next?”
Bartlet explained his catchphrase’s intent during a flashback to the campaign trail. Bartlet and his team are discussing strategies for securing his nomination for the presidency. When a character belabors a proposal, Bartlet counters, “I understood the point…. When I ask ‘What’s next?’ it means I’m ready to move on to other things. So, what’s next?”
So with regard to the Report and its usage and application in the medical, mental health, legal, corporate and governmental areas, the question needs to be asked, “What’s next?”