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SubscribeThe U.S. spends $3.7 trillion a year treating conditions that were largely preventable. The industry’s answer has been to charge patients more to access the care most likely to prevent them. There is a better way.
EXECUTIVE SUMMARY
The CDC estimates that 90% of all healthcare costs in the U.S. go toward treating chronic disease and mental health, roughly $3.7 trillion a year.¹ The vast majority of those conditions were preventable. The system’s response has been to charge patients copays and deductibles to access the primary care visits most likely to stop that spending before it starts, then absorb the far larger cost when disease arrives unchecked.
There is a better model: pay plan members and employees directly for completing preventive care.
The ROI data supports it. The behavioral science supports it. The only thing holding the system back is a reimbursement structure that profits more from treating illness than preventing it.
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The Partnership to Fight Chronic Disease projects that chronic disease is on pace to cost the United States as much as $47 trillion between 2024 and 2039, including $2.2 trillion annually in medical costs and nearly $900 billion each year in lost productivity by 2039.² That figure likely understates the problem.
More than a quarter of all U.S. healthcare spending is attributable to preventable illnesses,³ though given how much of the chronic disease burden is tied to lifestyle and metabolic risk, the real share may be considerably higher.
The leading risk factors, physical inactivity, poor nutrition, tobacco use, and excessive alcohol, account for more than 50% of preventable disease deaths in the United States, including those caused by cancer, chronic respiratory diseases, type 2 diabetes, and cardiovascular disease.⁴
Meanwhile, the percentage of total national healthcare spending directed at public health prevention initiatives ranged from just 1.1% to 5.9% in 2018.⁴
The system spends trillions treating conditions it could have interrupted for pennies on the dollar, then charges the patient a copay for the wellness visit that might have caught the problem early.
Annual wellness visits, PSA tests, blood pressure checks: the people skipping them understand what they’re doing. The incentive structure makes avoidance the more rational choice in the moment.
Start with the ACA’s promise of free preventive care. That promise has a trap built into it. The visit is free until something is found. The moment a clinician identifies a problem during a preventive encounter, it converts from a wellness visit to a diagnostic visit, and the patient receives a bill they weren’t expecting. The system has designed preventive care so that the more it works, the more it costs the patient.
The proliferation of high-deductible health plans compounds the problem. A patient facing a $10,000 deductible has no rational incentive to seek care early. They will wait until the condition is serious enough that the deductible becomes irrelevant, by which point the condition has advanced, the intervention is more complex, and the cost to the system is exponentially higher. About one in four patients with employer-sponsored insurance still receives a bill for a service that should have been free under the ACA’s cost-sharing exemption.⁶
Present biases prevent people from taking actions they know are in their long-term best interest, including checking blood sugar, getting cancer screenings, and attending preventive care visits.⁵ Financial friction at the point of access reinforces those biases. The $200 preventive visit feels discretionary until a condition advances to the point where it is not. By the time a patient presents at a hospital, deductible exposure is no longer a deterrent — the average readmission costs $15,500 per person, and the average inpatient day for a Medicare Advantage member runs $2,566.⁵ Those bills get paid without hesitation, and the system absorbs them as the predictable cost of a structure that discourages early intervention.
The answer is to flip the financial incentive entirely. Stop charging members to access preventive care and start paying them to complete it. A $50 payment for a completed annual wellness visit, a $75 reward for a cancer screening, a premium reduction tied to documented medication adherence: these are not giveaways. They are investments with a documented return that dwarfs the outlay.
A $10 per capita expenditure on community prevention is estimated to save $2.8 billion within one to two years, $16.5 billion within five years, and $18 billion over ten to twenty years, generating a return of roughly 6:1 over the medium and long term.⁷
A 2024 study by UPMC Health Plan published in the Journal of Managed Care and Specialty Pharmacy tested a financial incentive and refill reminder program on patients taking antithrombotic medications. Patients in the program were roughly 20 percentage points more likely to adhere to their medications than controls, and emergency department use fell by 16%. Drug spend increased modestly because patients were actually filling their prescriptions. Total cost of care did not increase. That is the core economic argument for paying members to engage: the system absorbs the incentive cost and comes out even on total spend, while patients get healthier and utilization falls.¹²
A cost-consequences analysis of an outreach facilitation intervention demonstrated that savings from reducing inappropriate testing and increasing appropriate screening can offset all intervention costs and result in a net savings of approximately two dollars for every rostered patient.⁸ Disease management programs targeting multiple health conditions have produced a positive ROI within one to two years.⁹ Better prevention and earlier intervention could prevent 150 million new chronic disease cases, save 13.5 million lives, and avoid $7 trillion in costs nationally between 2024 and 2039.²
In 2011, the ACA created the Medicaid Incentives for the Prevention of Chronic Disease grant program, awarding five-year grants to ten states to incentivize beneficiaries who participated in prevention programs and adopted healthier behaviors.¹⁰ States developed programs to curtail smoking, reduce obesity, and improve immunization rates, with the explicit goal of reducing program costs through behavioral change.¹¹ This is not a pilot concept. It is a proven mechanism that has not been scaled.
Here is where the life sciences industry has both the most to gain and the most to answer for.
Many companies routinely spend hundreds of millions developing therapies for conditions that were, at some proximal stage, preventable. Type 2 diabetes, cardiovascular disease, certain cancers, COPD: entire commercial franchises are built on the downstream consequences of behavioral risk factors that preventive engagement could have blunted or delayed.
Consider obesity: payers routinely deny coverage for obesity treatments until a patient presents with comorbidities and a BMI above 35. The system requires the disease to become expensive before it will pay to address it. The industry’s revenue model, in part, is built on exactly that logic.
Companies that continue building their value arguments exclusively around treating established disease, without generating evidence that their products also reduce total downstream cost, will find themselves in increasingly adversarial access negotiations with no differentiated story to tell.
The companies getting ahead of this are generating real-world evidence that connects their product to avoided costs. A biologic that controls a chronic inflammatory condition before it triggers a hospitalization carries a fundamentally different HEOR story than one positioned purely on symptom reduction. A digital therapeutic that improves medication adherence in pre-diabetic patients is not a wellness app. It is an actuarial intervention, and it should be priced and evidenced accordingly.
Eli Lilly’s Employer Connect platform, launched in March 2026, illustrates where the industry is heading. Rather than waiting for commercial payers to expand coverage for obesity management, Lilly went directly to self-insured employers, giving them flexible, cost-transparent access to Zepbound through a dedicated network of independent program administrators. The platform acknowledges what the traditional reimbursement system has resisted accepting: that obesity is a chronic disease worth treating before it generates the comorbidities that finally make it coverage-eligible. For life sciences companies watching from the sidelines, Employer Connect is a message. The access model is being rebuilt around employers and patients, and manufacturers who wait for payers to lead that rebuild will arrive late to a market that is already moving.
Employers represent an underutilized lever more broadly. Chronic disease drives absenteeism, reduced productivity, and turnover, and companies with high employee churn rarely account for how much of it is driven by workforce health. The employer who reduces average employee BMI, improves medication adherence, and closes care gaps improves their benefits trend while building a more productive organization. That argument belongs in the commercial strategy for any company in the metabolic or cardiovascular space.
Charging patients for preventive primary care while paying billions to manage the chronic disease that follows generates revenue at every stage of a patient’s decline. Primary care underfunding ensures patients arrive at specialty care sicker. Sicker patients require more intervention. More intervention generates more billable events.
Every major stakeholder in the current system, payers, providers, pharmaceutical manufacturers, hospital systems, benefits financially from the way things are structured. Every stakeholder, that is, except the patient. This system took shape in an era when healthcare budgets felt limitless and the goal was access, not efficiency. Those conditions no longer exist, but the incentive architecture remains intact.
Fee-for-service payment models reward volume, not outcomes. Capitated models shift risk onto providers but don’t necessarily change how downstream cost is managed. Commercial payers operate on roughly three-year enrollment cycles, meaning the long-term ROI of prevention, which often plays out over five to ten years, will be realized by a different payer than the one who paid for the intervention. That structural misalignment is why prevention, despite decades of evidence supporting its value, remains chronically underfunded.
The U.S. spends 16.9% of GDP on healthcare, nearly double the OECD average of 8.8%, and more than a quarter of that spending goes toward conditions that are preventable.³ At some point, the data stops being a policy debate and becomes an indictment.
Paying members to engage in preventive care is the financially rational response to a system that has demonstrably failed to produce health outcomes commensurate with its cost. The companies and plans that move first on this model will capture the cost savings, the quality metrics, the Star Ratings, and ultimately the market.
For commercial, market access, and HEOR executives in prevention-adjacent disease areas
Build the cost-of-inaction argument.
Payers make coverage decisions around total cost of care, not just clinical outcomes. Model what a patient costs the system without your intervention and put that number in the value dossier, before the formulary negotiation, not during it.
Redirect RWE toward avoided costs.
Hospitalizations prevented, ER visits reduced, downstream utilization bent: this is the evidence payers act on. If it sits in a HEOR appendix instead of driving the commercial narrative, it isn’t working hard enough.
Develop the employer channel.
Self-insured employers operate with longer time horizons and more flexibility than commercial payers. Workforce productivity, reduced absenteeism, lower disability claims: these are access arguments most commercial teams haven’t fully built. Lilly’s Employer Connect is the signal that this channel is open.
Invest in Proof of Concept Programs.
A 2024 UPMC Health Plan study found that a financial incentive and refill reminder program improved medication adherence by roughly 20 percentage points and reduced emergency department use by 16%, without increasing total cost of care. That is the evidence architecture payers need to justify paying members to stay on therapy, and it repositions your product from a cost center to a cost-neutral intervention.¹²
Align now to the access environment that is coming.
The coverage landscape is shifting toward early intervention. Companies that build their access strategy, evidence generation, and payer engagement around that logic today will not be scrambling to catch up when payers finish making the shift.
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Betsy J. Lahue is CEO of Alkemi, a life sciences consulting firm specializing in HEOR, Market Access, and Market Shaping.
Alkemi has contributed to launches representing tens of billions in global sales and partners with diagnostic and life sciences executives to build value and access strategies that translate clinical innovation into real-world adoption. To discuss your program, contact us at www.alkemihealth.com/contact
REFERENCES
1. Highmark. Chronic Disease Costs a Lot: How Care Management Can Help. https://www.highmark.com/employer/thought-leadership/health-insurance-cost-management/cost-of-chronic-health-conditions
2. Partnership to Fight Chronic Disease. New Report: Chronic Disease Could Cost the U.S. $47 Trillion Over Next 15 Years. December 2025. https://www.fightchronicdisease.org/post/new-report-chronic-disease-could-cost-the-u-s-47-trillion-over-next-15-years
3. Bolnick H, et al. The cost of preventable disease in the USA. PMC / NIH. https://pmc.ncbi.nlm.nih.gov/articles/PMC7524435/
4. Hacker K, et al. The Burden of Chronic Disease. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10830426/
5. Wellth Inc. Can member incentives lower health plan costs? https://www.wellthapp.com/news/can-member-incentives-lower-health-plan-costs
6. Schwartz K, et al. Out-of-pocket costs for preventive care persist almost a decade after the Affordable Care Act. Preventive Medicine. June 2021. https://www.sciencedirect.com/science/article/abs/pii/S0091743521002590
7. Levi J, et al. A Review and Analysis of Economic Models of Prevention Benefits. ASPE / U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/review-analysis-economic-models-prevention-benefits-0
8. Lemelin J, et al. Cost savings and cost-effectiveness of clinical preventive care. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC1079830/
9. Mattke S, et al. Return on Investment in Disease Management: A Review. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC4194913/
10. Centers for Medicare & Medicaid Services. Medicaid Incentives for the Prevention of Chronic Diseases Model. https://www.cms.gov/priorities/innovation/innovation-models/mipcd
11. Commonwealth Fund. Public Programs Are Using Incentives to Promote Healthy Behavior. https://www.commonwealthfund.org/publications/newsletter-article/public-programs-are-using-incentives-promote-healthy-behavior
12. Peasah SK, Liu Y, Krohe S, et al. Assessing the impact of a financial incentive and refill reminder program on medication adherence and costs. J Manag Care Spec Pharm. 2024;30(1):43-51.
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