Multiple Chronic Conditions: A Public Health Challenge

The number of Americans with chronic conditions has steadily increased in recent decades. Almost half of the American population suffers from chronic illness, the leading cause of death and disability in the U.S.¹ Defined as conditions that last a year or more and require ongoing care and/or limit activities of daily living, chronic conditions include hypertension, respiratory diseases, arthritis, heart disease, diabetes, cancer, and dementia, among others.² While it may not be surprising that more and more Americans have a chronic condition, what is striking is that almost one in four Americans (approximately 75 million people) have multiple chronic conditions (MCCs).³ It is not uncommon in today's hospitals and outpatient clinics for clinicians to examine and treat patients with five, six, or even seven chronic conditions. Remarkably, older adults with five or more chronic illnesses have, on average, 50 prescriptions filled, see 14 different physicians, and make 37 physician office visits per year.²

As individuals accrue more chronic conditions, health quality outcomes are reduced. Individuals with MCCs have higher mortality rates and suffer from poor functional status sooner than people with fewer chronic conditions.^3,4 They more frequently experience unnecessary hospitalizations, particularly for ambulatory-sensitive conditions, and more commonly experience adverse drug events. They also report receiving conflicting medical advice, duplicative tests, and more services.⁵ Thus, individuals in this population are particularly vulnerable to suboptimal quality care.⁴ This makes coordination of care more difficult, yet increasingly critical for this heterogeneous population.

The issue of MCCs also includes the associated substantial economic burden on the U.S. Of total health-care spending, 65% is on care for this population. Patients with more than one chronic condition account for 95% of all Medicare spending; those with more than five chronic conditions account for two-thirds.^3,6 Virtually all of the highest cost Medicaid beneficiaries have a complex mix of comorbidities and psychosocial needs.⁷ Predictably, health-care spending in general and total out-of-pocket spending increase with the number of chronic conditions present.² Yet, many of the health services needed for this population—home health, nutrition, mental health, and physical therapy—may not be covered by insurance or require significant cost sharing and, thus, increase consumer out-of-pocket expenses.³

Several potential reasons exist to explain the poor outcomes and high costs associated with MCCs. First, there is limited understanding of what constitutes optimal care of this burgeoning population. The majority of clinical guidelines do not contain specific recommendations for patients with comorbid conditions, so clinicians tend to follow several single-disease-specific guidelines, increasing the risk of adverse drug events and disease-disease interactions.⁸ The extent to which this population is included in clinical trials is also unclear.⁹ In addition, this population is extremely heterogeneous, yet epidemiologic research to determine the most prevalent subgroups of individuals with specific combinations of chronic conditions is limited.

Many health professionals feel their training did not adequately prepare them in competencies essential to the care of individuals with MCCs such as chronic pain, nutrition, medication management, self-care management, and interdisciplinary care.¹⁰ Even if they were prepared, there are few provider incentives in the current health-care financing system for care coordination and disease management across multiple conditions. Finally, it is unclear whether the benefits of self-care management, including in-home and community-based services designed to help individuals better manage their conditions, are being fully realized.

Given that this is such an important issue, the U.S. Department of Health and Human Services (HHS) is developing a draft strategic framework to achieve optimum health and quality of life for individuals with MCCs.¹¹ To achieve this vision, HHS has established four provisional overarching goals:

1. Provide better tools and information to health-care and social service workers who deliver care to individuals with MCCs.

2. Maximize the use of proven self-care management and other services by individuals with MCCs.

3. Foster health-care and public health system changes to improve the health of individuals with MCCs.

4. Facilitate research to fill knowledge gaps about individuals with MCCs.

Each of these goals includes several key objectives and strategies that HHS, in conjunction with external stakeholders and those individuals with MCCs, should utilize to guide its efforts. In partnership with the Office of the Surgeon General and other HHS agencies such the Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Food and Drug Administration, Health Resources and Service Administration, and Centers for Medicare & Medicaid Services, the Office of the Assistant Secretary for Health at HHS leads a departmental workgroup to help implement the framework and ensure a coordinated and comprehensive effort moving forward.

Though HHS seeks to bring awareness to these complex patients, understanding and treating their diverse needs is a shared responsibility. We must act now to optimize the health and quality of life of people with MCCs. I urge clinicians, researchers, and public health practitioners to champion this urgent initiative as we work to provide effective care in our health system and improve the health of our nation.

VADM Regina M. Benjamin, Surgeon General