People with multimorbidity consume a disproportionate amount of healthcare resources. Regardless of the way multimorbidity is defined (i.e. based on chronic condition counts, indices or measures of all types of conditions), higher levels of multimorbidity have consistently been shown to be associated with the largest share of resource consumption in numerous populations and settings around the globe (Lehnert, Heider, Leicht, et al., 2011). The following examples, though based on data from individual countries, depict a picture representative of healthcare delivery worldwide. Figure 4.1 describes the characteristics and healthcare use for a cohort of older Americans (65+) in the government-sponsored Medicare programme. People with five or more chronic conditions constitute about a fifth of the Medicare population, yet consume two-thirds of all healthcare resources (Anderson, Horvath, 2002).

Figure 4.2 depicts the association between multimorbidity and primary care visits, specialist visits, performance of diagnostic tests and hospitalizations within Israel’s Clalit Health Services, which is an integrated delivery system. The analysis in this figure uses the Aggregate Diagnostic Groups (ADGs) of the of the Johns Hopkins Adjusted Clinical Groups® (ACG) system, discussed in Weiner (1991), which measures multimorbidity across all types of conditions (both acute and chronic) the patient may have. As shown in Figure 4.2, multimorbidity explains a much larger share of resource use for each of the four types of healthcare resources assessed compared with that of age and gender alone (Shadmi, Balicer, Kinder K, Abrams, Weiner, 2011) (See Box 4.1).

Causal pathways

While the phenomenon of high resource consumption in people with multimorbidity is well described, how multimorbidity results

in excessive use of resources is less clear. Box 4.2 tells the story of how multimorbidity may result in high rates of resource use, using an example from the USA.

As depicted in Box 4.3, MM’s healthcare resource use is determined by the highly professionalized fragmented nature of the healthcare system in the USA, with multiple sub-specialty experts and lack of coordinating mechanisms that can definitively ensure

Box 4.2 Increased current and future resource use by levels of multimorbidity

Using private insurance data for a two-year cohort of Americans under the age of 65, we describe (Figure 4.3) the group by multimorbidity percentile levels, as defined by the Johns Hopkins ACG multimorbidity index. This figure shows that the greater the multimorbidity, as measured by the index percentile levels (from 0 to 10% up to 95 to 99%), the greater the number of chronic conditions, total number of conditions and number of drug therapeutic classes used. We go on to assess the impact of this year’s multimorbidity levels on future (year 2) resource use (Figure 4.4), showing a similar pattern. This ‘predictive’ type of analysis is critical for both reimbursement/budgeting (which usually uses past information to budget for future periods) and care management intervention designed to target and intervene individuals with the highest level of multimorbidity.

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