Funder: Kaiser Permanente Community Benefit and the Robert Wood Johnson Foundation

Author: Richard G. Kronick, Melanie Bella, Todd P. Gilmer, Stephen A. Somers

October 2007 | Report


Within the most expensive 1% of Medicaid beneficiaries, almost 83% had three or more chronic conditions, and over 60% had five or more chronic conditions.

The majority of Medicaid spending is driven by people with multiple chronic conditions. Greater understanding of these high-need, high-cost beneficiaries can help Medicaid stakeholders design programs to more effectively manage their care, improve their health outcomes, and reduce or control the costs of caring for them.

The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions, published by the Center for Health Care Strategies (CHCS), is a groundbreaking examination of the patterns of multiple chronic conditions among Medicaid beneficiaries. To develop a “portrait” of beneficiaries with comorbidities, CHCS worked with Rick Kronick, PhD, and Todd Gilmer, PhD, experts in Medicaid disease prevalence from the University of California, San Diego. The resulting data show that among high-cost Medicaid beneficiaries, virtually all have multiple chronic conditions. Key findings include:

  • Within the most expensive 1% of beneficiaries in acute care spending, almost 83% had three or more chronic conditions, and over 60% had five or more chronic conditions.
  • For Medicaid-only persons with disability, each additional chronic condition is associated, on average, with an increase in costs of approximately $700/month, or approximately $8,400 per year. There is evidence of “super-additivity” of costs (i.e., moving from seven to eight conditions adds more expenditures than moving from one to two conditions).
  • The top most prevalent diagnostic pairs of diseases, or “dyads,” among the highest cost 5% of patients are: cardiovascular-pulmonary (30.5%); cardiovascular-gastrointestinal (24.8%); cardiovascular-central nervous system (24.8%); central nervous system-pulmonary (23.8%) and pulmonary-gastrointestinal (23.8%).

These findings shed light on how Medicaid stakeholders can rethink care management approaches for high-need, high-cost beneficiaries with multimorbidity. Traditional disease management programs focused on single diseases that “silo” beneficiaries into disease specific interventions do not address the complex needs of those with multiple conditions. By clearly identifying the complex needs of these beneficiaries, states, plans, and providers can develop integrated and coordinated delivery systems that incorporate clinical care with behavioral and non-medical supportive services.