chronic conditions in the u.s. implications for service delivery and financing jane horvath,...
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Chronic Conditions in the U.S.Chronic Conditions in the U.S.Implications for Service Delivery and FinancingImplications for Service Delivery and Financing
Jane Horvath, M.H.S.A.Jane Horvath, M.H.S.A.Deputy DirectorDeputy Director
Partnership for SolutionsPartnership for SolutionsA Project of Johns Hopkins University and A Project of Johns Hopkins University and
The Robert Wood Johnson FoundationThe Robert Wood Johnson Foundation
Chronic Conditions in the U.S.Chronic Conditions in the U.S.
•Chronic conditions are expected to last a year or more, limit what one can do and may require ongoing care.
•Chronic conditions are a significant and growing challenge.
•People with chronic conditions have significantly higher utilization and health care costs.
•Coordination of services for people with chronic conditions is lacking.
•There are opportunities for change.
The Number of People with Chronic Conditions is Rapidly Increasing
Source: Wu, Shin-Yi and Green, Anthony. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000.
118
125
133
141
149
157
164
171
100
120
140
160
180
200
1995 2000 2005 2010 2015 2020 2025 2030
Year
Nu
mb
er
of
Peo
ple
Wit
h C
hro
nic
Co
nd
itio
ns
(mil
lio
ns)
Almost Half of People with a Chronic Condition have Multiple Chronic Conditions
24%
11%
5%4%
1%
0%
5%
10%
15%
20%
25%
30%
1 2 3 4 5+
Number of Chronic Conditions
Per
cen
t o
f A
ll A
mer
ican
s
Source: Wu, Shin-Yi and Green, Anthony, Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000.
1/4 of Individuals with Chronic Illness also have Activity Limitations
Both
30 Million 7 Million90 million
Activity Limitation OnlyChronic Illness Only
• Eighty-one percent of those with activity limitations also have a chronic condition.
• Although there are 37 million people with activity limitations living in the community, about 2.7 million adults are severely impaired and need assistance with three or more activities of daily living -- eating, dressing, getting in or out of a bed or a chair, or using the toilet (Feder, Komisar, and Niefeld, “Long-Term Care In The United States: An Overview,” Health Affairs 19:3, May 2000).
Source: Medical Expenditure Panel Survey, 1998.
n = 127 Million
Most People with Chronic Conditions have Private Health Insurance
Unknown2%
Other Govermnet Insurance
3%
65+ Medicare only 8%
Uninsured7%
65+ Medicare/ Private
13%
Medicaid9%65+ Medicare/
Medicaid3%
Private Insurance55%
.
Source: Medical Expenditure Panel Survey, 1998.
Population of People with Chronic Conditions in 1998 n =120 million
Health Care Spending for People with Chronic Conditions Accounts for 78 % of All Health Care Spending
78%
96%
97%
95%
68%
58%
77%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
All Americans
Ages 65+ with MedicareOnly
Ages 65+ with Medicareand Medicaid
Ages 65+ with Medicareand Private Insurance
Privately Insured
Uninsured
Medicaid Beneficiaries
Percent of Spending on People With Chronic Conditions
Source: Medical Expenditure Panel Survey, 1998.
Health Care Spending Increases with the Number of Chronic Conditions
$800
$1,900
$3,400
$5,600
$8,900
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
$11,000
0 1 2 3 4 5+
Number of Chronic Conditions
Ave
rage
Per
Cap
ita
Hea
lth
Car
e S
pen
din
g
Source: Medical Expenditure Panel Survey, 1998.
People with Chronic Conditions are the Heaviest Users of Medical Care
76%
72%
88%
96%
0% 20% 40% 60% 80% 100%
Inpatient Stays
Physician Visits
Prescriptions
Home HealthVisits
Percent of Services Used by People With Chronic Conditions
Source: Medical Expenditure Panel Survey, 1998.
4%
7%
12%
16%
26%
5%
9%
12%
16%
27%
12%14%
19%21%
34%36%
33%
3%
0%
10%
20%
30%
40%
0 1 2 3 4 5+Number of Chronic Conditions
Per
cent
of
Peo
ple
With
Inp
atie
nt H
ospi
tal S
tays
All No Limitations With Limitations
People with Multiple Chronic Conditions are Much More Likely to be Hospitalized
Source: Medical Expenditure Panel Survey, 1998.
More than Half of People with Serious Chronic Conditions Have Three or More Different Physicians
Number of Different Physicians Seen By People with Serious Chronic Conditions
2 Physicians26%
3 Physicians23%
4 Physicians15%
5 Physicians6%
6+ Physicians11%
No Doctors3%
1 Physician16%
Source: Gallup Serious Chronic Illness Survey 2002.
People with Chronic Conditions Report Getting Conflicting Advice
18%
17%
16%
14%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%
Had duplicate tests orprocedures
Received conflictinginformation from
providers
Received informationabout drug interactionsupon filling prescription
Received differentdiagnoses from different
providers
Percent of Population with Chronic Conditions Reporting Problem
Source: Chronic Illness and Caregiving, a survey conducted by Harris Interactive, Inc., 2000.
Physicians Believe that Poor Care Coordination Produces Bad Outcomes
Source: National Public Engagement Campaign on Chronic Illness–Physician Survey, conducted by Mathematica Policy Research, Inc., 2001.
24%
34%
34%
36%
44%
49%
54%
0% 10% 20% 30% 40% 50% 60%
Unnecessary nursing home placement
Experience of unnecessary pain
Patients not functioning to potential
Unnecessary hospitalization
Adverse Drug Interactions
Emotional problems unattended
Receipt of contradictory information
Ad
vers
e O
utc
omes
Percent of Physicians Who Believe that Adverse Outcomes Result from Poor Care Coordination
Poor Care Coordination Leads to Unnecessary Hospitalizations
0 718
36
62
95
131
169
219236
261
0
50
100
150
200
250
300
0 1 2 3 4 5 6 7 8 9 10+
Number of Chronic Conditions
Hos
pita
lizai
tons
for
A
mbu
lato
ry C
are
Sens
itiv
e C
ondi
tion
s P
er 1
000
Med
icar
e B
enef
icia
ries
Age
s 65
+
Source: Medicare Standard Analytic File, 1999.
How do we Improve the System?How do we Improve the System?
• Benefits– Medical necessity determinations and
policies
• Disease Management
• Payments– Clinical care case management fee– Pharmacy coordinator
• Quality– Care Coordination as a quality measure
for health systems
• Benefits– Medical necessity determinations and
policies
• Disease Management
• Payments– Clinical care case management fee– Pharmacy coordinator
• Quality– Care Coordination as a quality measure
for health systems