Management of Individuals With Multiple Chronic Conditions: A Continuing Challenge

ABSTRACT

Individuals with multiple chronic conditions (MCCs) represent a growing proportion of the adult population in the United States, particularly among lower-income individuals and people of color. Despite ongoing efforts to characterize this population and develop approaches for effective management, individuals with MCCs continue to contribute substantially to health care expenditures. Based on a review of recent literature, several identified barriers limit the effectiveness of care for patients with MCCs. Health care delivery system structural limitations, evidence-based care concerns, patient-clinician relationship constraints, and barriers to inclusion of patient-centered priorities may singly or in combination negatively affect outcomes for individuals with MCCs. The COVID-19 pandemic has shed further light on inequities contributing to suboptimal MCC patient management. Awareness of the prevalence and demographic attributes of patients with MCCs and the identified barriers to care may help improve patient engagement and treatment outcomes for this high-cost population. This paper provides recommendations for enhancing MCC patient care outcomes in the current and post–COVID-19 health care delivery settings.

Am J Manag Care. 2021;27(6):256-260. https://doi.org/10.37765/ajmc.2021.88665

Takeaway Points

Individuals with multiple chronic conditions (MCCs) contribute significantly to health care expenditures, yet a systematic, patient-centered approach to care is uncommon. This paper provides a synopsis of recent insights regarding management of patients with MCCs and offers considerations for stakeholder actions, including:

• characterization of the prevalence, associated conditions, and cost trend of patients with MCCs;
• adoption of more equitable benefits offerings, recognizing that patients with MCCs are generally in lower-income categories;
• use of patient-centered care management approaches that address patient priorities, including social needs and behavioral health concerns; and
• enhanced use of virtual care, given increased COVID-19–related morbidity and mortality risk among patients with MCCs.

The presence of multiple chronic conditions (MCCs) is associated with increased mortality risk and functional impairment, along with greater use of health care resources and associated expenditures.¹ Although MCCs increase in prevalence with age and occur in approximately two-thirds of Medicare beneficiaries,² over the past several years, the proportion of working-age adults with MCCs has been steadily increasing.² Yet, despite the employer cost of these individuals in relation to health benefits, illness-related presenteeism, absence, and disability,³ this subpopulation has received comparatively little attention. Notably, MCCs are more common among lower-income individuals,^4,5 who face additional hurdles related to health care affordability. The goal of this paper is to provide insights regarding individuals with MCCs and evidence-based care needs as a basis for developing targeted health management strategies.

Background

As defined, individuals with MCCs have 2 or more concurrent chronic behavioral or physical conditions. Chronic conditions have been characterized as illnesses “that last a year or more and require ongoing medical attention and/or limit activities of daily living.”⁶ Although care for these individuals has been central to the practice of medicine, their significance was elevated with the release in 2001 of the landmark report Crossing the Quality Chasm, which highlighted the substantial costs associated with chronic care management and the challenges of care collaboration needs, particularly for patients with comorbid conditions.⁷ In 2008, HHS convened an interagency work group to develop an approach to improve MCC care, culminating in the 2010 release of a strategic framework that provides foundational management principles for these individuals.¹ The framework includes 4 overarching goals:

1. Fostering health care and public health system changes to improve the health of individuals with MCCs
2. Maximizing the use of proven self-care management and other services by individuals with MCCs
3. Providing better tools and information to health care, public health, and social services workers who deliver care to individuals with MCCs
4. Facilitating research to fill knowledge gaps about, and interventions and systems to benefit, individuals with MCCs

Despite these efforts, however, the prevalence of MCCs has increased, particularly among working-age adults. The Figure^2,8 shows the interval change from 2007 to 2017 in the distribution of chronic conditions within this population.² As shown, the proportion of individuals with 0 or 1 chronic conditions has fallen during this time period, with a commensurate increase in the proportion of individuals with 4 or more chronic conditions.

Primary disease states among individuals with MCCs include hypertension (27.0%), hyperlipidemia (21.1%), mood disorders (11.9%), diabetes (10.4%), and anxiety disorders (9.7%).⁸ Notably, the list of 21 chronic conditions⁹ initially selected by HHS for its work and broadly used in MCC-related research does not include obesity, formally recognized as a chronic disease by the American Medical Association in 2013. Given the 42% nationwide prevalence of obesity among adults,¹⁰ if it were included as an eligible condition in the HHS list, the prevalence of MCCs in working-age adults would undoubtedly be substantially greater.

Health care utilization and costs associated with care of patients with MCCs are significant. A 2017 RAND Corporation study observed that increasing numbers of MCCs were associated with disproportionate increases in emergency department use, inpatient hospitalizations, outpatient care, and medication use.⁸ Costs also increased in association with increasing number of chronic conditions, such that the 12% of the population with 5 or more chronic conditions was responsible for 41% of overall health care spending. Those with 3 or 4 conditions represented 16% of the population and 26% of total spending, whereas those with 1 or 2 conditions represented 31% of the population, driving 23% of spending. Individuals with no chronic conditions represented 40% of the population and were associated with just 10% of total health care spending. Given the sustained nature of MCCs and the risk of development of disease-specific complications, significant opportunities exist for improved condition management, with the potential for improved health and cost outcomes.

Care Management Issues

Ongoing challenges associated with care for patients with MCCs are well documented. Representative concerns can be separated into broad categories: delivery system issues, evidence-based care considerations, patient-clinician relationship concerns, and patient-centered priorities (Table^11-18).

In relation to delivery systems, lack of coordination between the primary care practitioner and specialists may limit care delivery effectiveness, yielding suboptimal outcomes. Instead, integrated team-based care that includes as-needed specialist input can likely provide more efficacious management of patients with MCCs. Meaningful information exchange between involved specialists and primary care can facilitate care management, especially when treatment options for one condition may have potentially deleterious impacts on the outcomes of another. Integration of behavioral health services can be valuable,¹⁹ particularly given the prevalence of behavioral health disorders within this population.¹¹

Additionally, evidence-based care considerations remain due to the fact that treatment guidelines are largely condition-centric. Some treatment guidelines, such as for heart disease, incorporate treatment for risk factors (hypertension, obesity, and hyperlipidemia) that themselves are chronic conditions. Other guidelines may include limited detail regarding management of comorbid conditions but may not necessarily incorporate the complexity of potential condition-condition interactions. Additionally, the risk of polypharmacy among individuals with MCCs is significant, particularly in relation to drug-drug interactions, along with the complexity and cost of medication regimens among these individuals.²⁰

Further, patient-clinician relationship concerns encompass an array of factors that ultimately affect patient adherence to recommended care. Lack of trust or “connectedness”¹² can undermine clinician effectiveness at addressing care priorities. Clinician time or other resource constraints may limit the ability to address the array of clinical and other issues that patients with MCCs may have, especially if social needs represent a barrier to treatment compliance.¹³

Finally, elucidation of patient-centered goals for treatment, including short- and long-term outcomes, affordability, and quality of life, may be inadvertently overlooked due to the complex clinical demands of patients with MCCs. Clarity in these areas of patient preference may help shift treatment priorities, ultimately improving patient experience.^14,21 Importantly, insurance status also affects health outcomes. Although the majority of working-age individuals have employer-sponsored insurance, many working-age adults either are underinsured or do not have health insurance. For these individuals, affordability and access concerns may pose a significant barrier to appropriate clinical care.

In the primary care setting, these combined issues can create particular challenges to effective management of patients with MCCs. Given the greater prevalence of MCCs among individuals in lower socioeconomic groups, concerns related to social needs, health literacy, and affordability have the potential to contribute negatively to treatment outcomes if they are not meaningfully addressed.

Issues for Payers and Plan Sponsors

Recognition among payers and plan sponsors of the significance of MCCs has been slow to materialize. Traditional medical/pharmacy claims and health risk assessment analysis is largely condition-focused, quantifying the occurrence and severity of specific chronic diseases among enrollees. Although this provides insight into condition prevalence, it fails to provide an individual-centric view of the number and nature of chronic conditions that individuals with MCCs may have. Additionally, the specific conditions included under the umbrella of “MCCs” have not been formally established,^15,22 further confounding the development of a consistent analytic approach. As a result, few stakeholders are likely aware of the prevalence and cost of MCCs within their benefits-enrolled populations.

Further, treatment options for chronic conditions are typically disease specific and may fail to address the complexities of concurrent treatment of MCCs in affected individuals, particularly when behavioral health issues are involved. Notably, the combination of both behavioral health conditions and physical health disorders among individuals with MCCs is associated with significantly more lost productivity and costs for the associated nonbehavioral health conditions.^19,23 However, identifying these individuals and providing targeted management is not typically an employer health care strategy.

Finally, less than 10% of employers have incorporated income-based subsidies for health benefits,²⁴ although some have lowered cost barriers to (primarily generic) medications for treatment of MCCs.²⁵ With low socioeconomic status associated with a higher prevalence of MCCs,⁴ affordability concerns create challenges for these individuals to optimize their care. Importantly—especially for employers interested in addressing diversity, equity, and inclusion concerns—the prevalence of MCCs is disproportionately greater among Black and Hispanic individuals,² representing a likely opportunity for intervention.

The Opportunity—and Practical Considerations

In the decade since the publication of the HHS framework for management of patients with MCCs,^1,26 the prevalence and complexity rates of MCCs have increased. Health care affordability concerns have also increased, particularly among low-wage earners enrolled in increasingly popular high-deductible health plans. Additionally, social determinants of health are now widely recognized as nonclinical barriers to care for patients.

For employers, the increasing prevalence of MCCs among working-age adults, coupled with the associated sustained high health care costs²⁷ and delayed retirement,²⁸ make focused intervention an opportunity that is likely of high value. Realized cost savings may originate in the near term from reduction in the number of chronic condition–related avoidable hospitalizations and emergency department visits. Longer-term savings may be generated from avoidance of complications from chronic conditions that are suboptimally managed. Additionally, with improved condition management, individuals are likely to realize improvements in workplace performance and have fewer illness-related absences.

Plan sponsors will benefit from first understanding the prevalence of MCCs and associated health care expenditures as well as the demographics (age, tenure, and job category) within their benefits-enrolled population. If these data are significant, plan sponsors may derive benefit from more detailed claims analysis to understand health care utilization patterns, particularly in relation to avoidable costs, such as high-intensity health care services use (emergency department visits and condition-related hospitalizations). Focus groups of benefits enrollees can be engaged to understand the experiences of individuals with MCCs who are receiving care to identify and mitigate barriers to effective treatment.

Importantly, the COVID-19 pandemic has likely had a disproportionately negative impact on those with MCCs. Not only is this subpopulation at greater risk for COVID-19–related hospitalization, morbidity, and mortality,¹⁶ but many individuals have delayed or forgone their chronic condition care,²⁹ increasing the risk of disease-specific complications. The MCC population is also more likely to be at risk for job loss, with the concomitant loss of employer-sponsored insurance further complicating access to and affordability of ongoing care.

As part of the redesign of health care services delivery in the postpandemic setting, the needs of individuals with MCCs may be more meaningfully addressed by ensuring a structured and holistic approach to care that extends beyond a traditional clinical focus. Important considerations include recognition and support for both social needs and behavioral health concerns that may impair the effectiveness of care delivery. Because of COVID-19–associated increases in morbidity and mortality risk for this subpopulation, new ways to engage individuals to ensure ongoing adherence to care are necessary. Virtual visits can facilitate greater patient access and engagement, although it is important to address potential barriers to technology use.

From the employer perspective, increased awareness of existing inequities in benefits design may encourage more employers to incorporate benefits subsidies for lower-income individuals in the form of differential wage-based premium subsidies or health savings account contributions.²⁴ For chronic care management, the adoption of value-based insurance design, with predeductible coverage to promote ongoing compliance with chronic care, may also improve engagement rates,²⁵ particularly given the financial barriers to care that individuals with MCCs may face.

It is critical to recognize the level of comprehensive support that is needed to effect health behavior change among individuals with MCCs. Because factors contributing to each patient’s current status are often multifactorial and interrelated, a holistic and comprehensive solution that targets each individual’s unique needs is most likely to yield the greatest level of benefit.

Conclusions

Individuals with MCCs—disproportionately in lower socioeconomic groups and often with behavioral health issues—represent a steadily growing population whose multidimensional needs are not being well addressed by the current health care delivery system. All stakeholders have an opportunity to better understand the prevalence and cost of individuals with MCCs. Health plans and delivery systems can evaluate the effectiveness of current approaches to comprehensive management, and plan sponsors can gain insights into health care utilization patterns and costs, along with barriers to appropriate care. Equipped with this knowledge, they can be empowered to more effectively meet the complex care management needs of this subpopulation.

Author Affiliations: Cone Health, Greensboro, NC; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH.

Source of Funding: None.

Author Disclosures: Dr Sherman is an advisor for Cone Health and Inspera Health and received speaking fees from Inspera Health for a panel presentation.

Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; provision of patients or study materials; administrative, technical, or logistic support; and supervision.

Address Correspondence to: Bruce W. Sherman, MD, 117 Kemp Rd E, Greensboro, NC 27410. Email: bruce.sherman@case.edu.

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