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A
C O R P O R A T I O N
Multiple Chronic Conditions in the United States
Christine Buttorff, Teague Ruder, and Melissa Bauman
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I
In 2014, 60 percent of Americans had at least one chronic
condition, and 42 percent had multiple chronic conditions.
These proportions have held steady since 2008. Americans
with chronic conditions utilize more—and spend more on—
health care services and may have reduced physical and
social functioning. This chartbook updates previous versions
with more recent data on the prevalence of multiple chronic
conditions (2008–2014) and associated health care utilization
and spending. It explores disparities in the prevalence of chronic
conditions and associated utilization of health care services and
analyzes functional or other limitations for those with multiple
chronic conditions. This chartbook should be of interest to
researchers, policymakers, and practitioners, as well as to the
general public.
The authors would like to thank the Partnership to Fight Chronic
Disease for providing support for this project. We also thank our
reviewers, Chloe E. Bird, Ph.D., and Gerard F. Anderson, Ph.D.,
for lending their expertise to this report.
This research was conducted in RAND Health, a division of
the RAND Corporation. A profile of RAND Health, abstracts of its
publications, and ordering information can be found at
www.rand.org/health.
Preface
iii
II
Contents
Preface ................................................................................................................................................. iii
Figures and Tables ................................................................................................................................v
Introduction ...........................................................................................................................................1
Methodology .........................................................................................................................................3
Chapter 1: Prevalence of Multiple Chronic Conditions .........................................................................5
Chapter 2: Health Service Use and Spending ...................................................................................13
Chapter 3: Functional Status of Adults with Multiple Chronic Conditions ..........................................18
Appendix: Detailed Methodology and Limitations .............................................................................21
References ..........................................................................................................................................27
iv
iii
Figures and Tables
Figure 1.1. Percentage of U.S. Adults with Chronic Conditions, by Number of Chronic
Conditions (2014) ...............................................................................................................................6
Figure 1.2. Prevalence of Multiple Chronic Conditions, by Age (2008–2014) ..........................................7
Figure 1.3. Prevalence of Multiple Chronic Conditions by Age and Gender (2014) ................................8
Figure 1.4. Percentage of U.S. Adults with One or More Chronic Conditions by
Race/Ethnicity (2014) .........................................................................................................................9
Figure 1.5. Prevalence of Top Chronic Conditions, 2014 ........................................................................10
Figure 1.6. Most Common Chronic Conditions in 2008 and 2014, Men ................................................11
Figure 1.7. Most Common Chronic Conditions in 2008 and 2014, Women ...........................................12
Figure 2.1. Annual Service Utilization by Number of Chronic Conditions (2014) ...................................14
Figure 2.2. Prevalence and Spending by Number of Chronic Conditions (2014) ..................................15
Figure 2.3. Health Care Spending by Number of Chronic Conditions (2014) ........................................16
Figure 2.4. Average Annual Health Care Expenditures, by Number of Chronic Conditions
and Insurance Type .........................................................................................................................17
Figure 2.5. Out-of-Pocket Spending by Number of Chronic Conditions and Insurance Type ..............17
Figure 3.1. Functional, Physical, Social, and Cognitive Limitations, by Number of Chronic
Conditions (2014) .............................................................................................................................19
Figure 3.2. ADL, Instrumental ADL, and Cognitive Limitations by Age and Number of Chronic
Conditions (2014) .............................................................................................................................20
Figure A.1. Prevalence of Multiple Chronic Conditions (2003–2014) .....................................................25
Figure A.2. Prevalence of Multiple Chronic Conditions in Adults Age 65 and Older, 2008–2013 ........26
Table A.1. Decision Rules for Imputing Masked Conditions ...............................................................22
v
1
Introduction
Six in ten adult Americans had at least one chronic condition
in 2014, the latest year for which data are available, and
four in ten had more than one. As this chartbook shows, chronic
disease is a burden not only for these patients but also for the
health care system overall. Those with multiple chronic conditions
have poorer health, use more health services, and spend more
on health care—trends that have been stable since 2008.
This chartbook assesses the prevalence of multiple chronic
conditions in the United States and explores the associated
health care utilization and medical spending. This version
updates and expands on previous editions: the Agency for
Healthcare Research and Quality’s (AHRQ’s) 2014 edition of
the Multiple Chronic Conditions Chartbook,10 as well as previous
iterations from the Robert Wood Johnson Foundation and Johns
Hopkins University.11, 12
The data confirm that the prevalence of multiple chronic
conditions—that is, having two or more chronic diseases
simultaneously—is highest among older adults. It also shows
that women are more likely than men to have multiple chronic
conditions, as many women live longer than men do. The
What is a chronic condition?
A chronic condition is a physical
or mental health condition that
lasts more than one year and
causes functional restrictions or
requires ongoing monitoring or
treatment.7
When a patient has more than one
chronic condition—for example,
diabetes, hypertension, and
mood disorders—treatment can
be difficult to manage. Treatment
strategies or drug regimens
may be similar—but can be
very different—and one chronic
condition may be better managed
than the others.1
Introduction | 1
2
prevalence of multiple chronic conditions is higher in non-
Hispanic whites than in other racial/ethnic groups, which may
reflect differences in access to care, rather than in the actual
prevalence of chronic disease. In addition, those with more
conditions have greater reported functional, social, and cognitive
limitations.
For policymakers, planning for the care of people with complex
chronic conditions is increasingly urgent as baby boomers
become eligible for Medicare. Previous work has shown that
people with multiple chronic conditions face more financial
obligations and functional limitations2, 3 and often have worse
health outcomes.4, 5, 6 Other work has shown that people with
multiple chronic conditions have higher hospital readmission
rates7 and much higher health care expenses.8 Multiple physical
health conditions can be difficult to manage, especially when
coupled with depression or other mental health conditions. In
addition, younger generations can be affected by the financial
and social implications of caring for the millions of older
Americans.9
Introduction | 2
3
Methodology
This study uses the Medical Expenditure Panel Survey
(MEPS) from AHRQ.13 MEPS is a publicly available, nationally
representative sample of the U.S. civilian, noninstitutionalized
population. It is important to note that institutionalized adults are
excluded from the charts because they are not included in the
MEPS data.
For the purposes of this chartbook, we define multiple chronic
conditions as having two or more conditions. We used the MEPS
survey weights to create nationally representative estimates.
We attempted to replicate the methods of earlier chartbooks.
Similar to previous iterations, this version identifies distinct
conditions using the Clinical Classification Software codes that
are part of the MEPS dataset, which group individual International
Classification of Diseases, ninth edition (ICD-9) diagnosis codes
into distinct conditions.14 To identify which conditions are chronic,
we used the Chronic Conditions Indicator, developed by Hwang
and colleagues.15, 16
Most of the charts in this book use data from 2014, the most
recent year available for adults 18 and older. In the 2007–2008
panels, MEPS added a set of questions specifically asking
whether respondents had certain priority conditions; as a
result, there is a marked increase in the reported prevalence of
chronic conditions overall at this point. Therefore, we restrict the
presentation of trends in prevalence of chronic conditions over
time to 2008–2014.
Our results have several limitations that should be taken into
account when using charts from this publication. The results may
underestimate the prevalence of chronic conditions because
the data do not include individuals living in institutions, who
Methodology | 3
4
may have a larger number of chronic conditions. While the
population of institutionalized adults is small for those ages
18–64, older adults are more likely to be in long-term care
facilities, so we may underestimate the prevalence among older
adults. About 3 percent of adults 65 and older were in full-year
long-term nursing care facilities in 2013, the latest year for
which data are available from the Medicare Current Beneficiary
Survey.17 Because MEPS is a survey that relies on respondents
to report on their own health, the data may also underrepresent
the actual prevalence of chronic disease if individuals are not
aware that they have the condition. We can only measure the
prevalence of those who have been treated or told by a health
care provider that they have a chronic condition (also called
the “treated prevalence”). Finally, it has been documented
elsewhere that MEPS underestimates total spending on health
care services, and the underestimate can be as much as
17.6 percent, depending on the service type.18 The estimates
on average spending should, therefore, be interpreted with
caution. Despite these limitations, MEPS is one of the best
sources of data on U.S. health care utilization, spending,
access to care, insurance coverage, and demographic
information.
A full description of the methodology can be found in the
appendix.
Methodology | 4
5
Prevalence of Multiple Chronic Conditions
CHAPTER 1
6
As of 2014, 60 percent of American adults had at least one chronic condition, and 42 percent had more than one chronic condition.
NOTE: Percentages may not total 100 because of rounding.
Figure 1.1. Percentage of U.S. Adults with Chronic Conditions, by Number of Chronic
Conditions (2014)
42% had more than one chronic condition 60% had at least
one chronic condition
12% of U.S. adults had five or more chronic conditions
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 6
40%had no chronic
conditions
18%
13%
9%
7%
12%
5+
4
3
2
Number of chronic conditions
1
0
7
The prevalence of multiple chronic conditions is higher among older adults.
PE
RC
EN
TAG
E O
F A
DU
LTS
WIT
H M
ULT
IPL
E C
HR
ON
IC C
ON
DIT
ION
S
90
2008 2009 2010 2011 2012 2013 2014
80
70
60
50
40
30
20
10
0
81%
50%
18%
42%
Figure 1.2. Prevalence of Multiple Chronic Conditions, by Age (2008–2014)
YEAR
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 7
65 years and older
45–64 years
Overall
18–44 years
Over time, the prevalence of U.S. adults with multiple chronic conditions has remained steady, at
around 42 percent.
8
Women ages 18 through 64 have a higher prevalence of multiple chronic conditions than men.
Figure 1.3. Prevalence of Multiple Chronic Conditions by Age and Gender (2014)
90
18–44 years
80
70
60
50
40
30
20
10
0
45–64 years 65 years and over
14%
22%
54%
47%
82% 81%
The presence of multiple chronic conditions increases with age for both genders. Because our
estimates of prevalence are based on self-reported conditions, we do not know if the higher
prevalence among women is a result of true differences in prevalence or of other factors, such as
women being more likely to be diagnosed because they may visit their health care providers more
often.19
Gender gapJust over 100 million people have multiple chronic conditions, and 54 million of them are women.
MEN
WOMEN
PE
RC
EN
TAG
E O
F A
DU
LTS
WIT
H M
ULT
IPL
E C
HR
ON
IC C
ON
DIT
ION
S
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 8
9
PE
RC
EN
TAG
E O
F A
DU
LTS
WIT
H O
NE
OR
MO
RE
CH
RO
NIC
CO
ND
ITIO
NS
Non-Hispanic whites have a higher reported prevalence of chronic conditions than other racial or ethnic groups.
Figure 1.4. Percentage of U.S. Adults with One or More Chronic Conditions by Race/Ethnicity (2014)
The difference between racial/ethnic groups for those with one chronic condition varies from a high of 63 percent for non-Hispanic whites to a low of 49 percent for Hispanics.
70
Non-Hispanic white
60
50
40
30
20
10
0
Non-Hispanic black
Non-Hispanic other
HIspanic
63%
58%
50%49%
NOTE: Estimates have been age-adjusted for the overall U.S. age distribution.
One reason could be that nonwhite racial/ethnic groups have historically had less access to
insurance and health care services, making it less likely that their conditions would be diagnosed
or treated. The non-white population is also younger; however, we do age-adjust the data.
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 9
14-point gap across racial/ethnic groups
10
Figure 1.5. Prevalence of Top Chronic Conditions, 2014
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 10
Hypertension and high cholesterol were the most common chronic conditions in 2014.
Heavy on heart disease One in four U.S. adults has hypertension, and about one in five has high cholesterol.
Hypertension
Lipid disorders (e.g., high cholesterol)
Inflammatory joint disorders (other than arthritis)
Osteoarthritis
Asthma
Coronary atherosclerosis and other heart disease
0 5 10 15 20 25 30PERCENTAGE
Mood disorders (e.g., depression, bipolar disorder)
Diabetes mellitus
Anxiety disorders (e.g., anxiety, panic disorders, stress)
Other upper respiratory disorders (e.g., chronic
laryngitis, chronic sinusitis)
27.0%
21.6%
11.9%
10.4%
9.7%
7.4%
7.4%
6.5%
6.3%
4.8%
11
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 11
Figure 1.6. Most Common Chronic Conditions in 2008 and 2014, Men
MEN
The prevalence of hypertension increased by 2.5 percentage points for men, and anxiety disorders
increased by 4.4 percentage points for women. The reported prevalence of mental health
conditions also increased from 2008 to 2014.
Hypertension
Lipid disorders (e.g., high cholesterol)
Diabetes mellitus
Mood disorders (e.g., depression, bipolar disorder)
Coronary atherosclerosis and other heart disease
Inflammatory joint disorders (other than arthritis)
Other upper respiratory disorders (e.g., chronic
laryngitis, chronic sinusitis)
Anxiety disorders (e.g., anxiety, panic disorders,
stress)
Asthma
Other upper respiratory infections (e.g., specific
types of chronic sinusitis)
0 5 10 15 20 25 30
24.9%27.4%
22.3%23.0%
2008
2014
9.2%10.5%
6.6%8.6%
6.4%5.8%
6.1%6.6%
5.9%5.8%
4.4%6.3%
4.3%4.5%
3.8%3.9%
PERCENTAGE
For women, the prevalence of anxiety disorders increased the most between 2008 and 2014, while hypertension increased the most for men.
2.5-percentage-point increase in hypertension among men
*
*
*
*
* Differences are significant at the p < 0.05 level or below.
12
WOMEN
Hypertension
Lipid disorders (e.g., high cholesterol)
Mood disorders (e.g., depression, bipolar disorder)
Other upper respiratory disorders (e.g., chronic laryngitis, chronic sinusitis)
Diabetes mellitus
Anxiety disorders (e.g., anxiety, panic disorders, stress)
Osteoarthritis
Inflammatory joint disorders (other than arthritis)
Asthma
Other upper respiratory infections (e.g., specific types of chronic sinusitis)
30 25 20 15 10 5 0
26.5%26.5%
21.8%20.3%
12.9%15.1%
9.3%9.0%
9.3%10.3%
8.4%12.8%
8.2%8.7%
7.8%8.2%
7.2%8.0%
7.2%6.7%
CHAPTER 1 | Prevalence of Multiple Chronic Conditions | 12
PERCENTAGE
2008
2014
* Differences are significant at the p < 0.05 level or below.
4.4-percentage-point increase in anxiety disorders among women
Figure 1.7. Most Common Chronic Conditions in 2008 and 2014, Women
*
*
*
*
*
From these data, we are unable to determine whether the apparent uptick in reported mental health
conditions reflects an increase in diagnosis and reporting (possibly stemming from a decrease in
stigma) or an increase in the prevalence of the diseases.
13
Health Service Use and Spending
CHAPTER 2
14
CHAPTER 2 | Health Service Use and Spending | 14
Health service use and spending is higher for those with chronic conditions than for those who are healthy.
Figure 2.1. Annual Service Utilization by Number of Chronic Conditions (2014)
The more chronic conditions people have, the more they use services of all types. As one example,
those with five or more chronic conditions use twice as many drugs on average per year, compared
with those with three or four conditions. As another, people with five or more conditions averaged 20
doctor visits per year, compared with 12 visits for those with three or four conditions.
3–4
EMERGENCY DEPARTMENT VISITS
PE
RC
EN
TAG
E W
ITH
AT
LE
AS
T O
NE
ED
VIS
IT
1–20 5+
35
30
25
20
15
10
5
0
32%
20%
14%
7%
OUTPATIENT VISITS
AV
ER
AG
E N
UM
BE
R O
F V
ISIT
S
3–41–20
25
20
15
10
5
5+0
20
12
6
2
PRESCRIPTIONS
AV
ER
AG
E N
UM
BE
R O
F
PR
ES
CR
IPT
ION
S F
ILL
ED
3–41–20
60
50
40
30
20
10
5+0
51
24
9
1
INPATIENT STAYS
PE
RC
EN
TAG
E W
ITH
AT
LE
AS
T O
NE
IN
PA
TIE
NT
STA
Y
3–41–20 5+
24%
10%
6%
3%
NOTES: Average utilization is presented; not everyone uses a particular service in a given year, especially inpatient stays and ED visits. The number of prescriptions represents the total number of fills, including refills, not necessarily unique active ingredients, such as acetaminophen or ibuprofen.
NUMBER OF CHRONIC CONDITIONS
35
30
25
20
15
10
5
0
NUMBER OF CHRONIC CONDITIONS
NUMBER OF CHRONIC CONDITIONS NUMBER OF CHRONIC CONDITIONS
15
Americans with five or more chronic conditions make up 12 percent of the population but account for 41 percent of total health care spending.
Figure 2.2. Prevalence and Spending by Number of Chronic Conditions (2014)
90
Total population
80
70
60
50
40
30
20
10
0Total expenditures
PE
RC
EN
TAG
E
NOTE: Total health care spending defined as the amount spent on all outpatient and inpatient health care services across all payers, including out-of-pocket payments.
Percentages may not total 100 because of rounding.
100
12%
16%
31%
40%
41%
26%
23%
10%
5+
3–4
1–2
0
Number of chronic conditions
CHAPTER 2 | Health Service Use and Spending | 15
16
People with chronic conditions have higher health care spending.
Figure 2.3. Health Care Spending by Number of Chronic Conditions (2014)
Those with five or more chronic conditions spend twice as much on average as those with three
or four conditions, with the majority of that additional spending going to office visits, inpatient
visits, and prescriptions.
20,000
0
18,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
AV
ER
AG
E A
NN
UA
L S
PE
ND
ING
PE
R P
ER
SO
N IN
DO
LL
AR
S
NOTE: Total health care spending is defined as the amount spent on health care services across all payers, including patient out-of-pocket payments.
Average utilization is presented; not everyone uses a particular service in a given year, especially inpatient stays and ED visits.
1–2 3–4 5+
16,000
Other
Home health
Prescription
ED
Office and outpatient
Inpatient
NUMBER OF CHRONIC CONDITIONS
14 times more spending On average, Americans with five or more chronic conditions spend 14 times more on health services than people with no chronic conditions.
CHAPTER 2 | Health Service Use and Spending | 16
17
CHAPTER 2 | Health Service Use and Spending | 17
Spending on health care services increases with number of chronic conditions but varies by insurance type.
Figure 2.4. Average Annual Health Care Expenditures, by Number of Chronic
Conditions and Insurance Type
Figure 2.4 displays payments for health care spending from other payers, such as Medicare or private
insurance. An important caveat is that this figure does not account for other social supports to manage
chronic conditions, such as unpaid caregiving from family members.
Medicare
Other public
Private
5+
3–4
1–2
0
Number of chronic conditions0 25,000
DOLLARS
20,00015,00010,0005,000
$17,640
$8,867
$5,272
$1,973
$20,763
$9,864
$4,107
$1,397
$18,351$8,349
$4,241
$1,533
0
DOLLARS
Medicare
Other public
Private
$1,792
$1,137
$741
$378
$808
$640
$242
$92
$1,741
$1,201
$698
2,000 1,000 750 500 2501,750 1,500 1,250
$295
Figure 2.5 Out-of-Pocket Spending by Number of Chronic Conditions and
Insurance Type
18
CHAPTER 3
Functional Status of Adults with Multiple Chronic Conditions
19
CHAPTER 3 | Functional Status of Adults with Multiple Chronic Conditions | 19
Individuals with more chronic conditions have greater difficulties with activities of daily living (ADL) and other social and cognitive functions that are important to patients’ independence.
People with five or more conditions have more than double the number of these limitations than those with
three or four conditions, and the greater functional limitations place higher demands on caregivers and the
health care system.
NOTES: ADL include such basic functions as being able to bathe, dress, eat, go to the bathroom, or do light activity—for example, walking up a flight of stairs. Instrumental ADL include light housework, preparing meals, paying bills, and shopping. We used the composite variables constructed in MEPS for the ADL and IADL, which indicate whether a person reported needing supervision to complete at least one ADL or instrumental ADL activity. A work/school/home limitation is defined as an impairment or a physical or mental health problem that limits a person’s ability to work at a job, do housework, or go to school. A physical limitation is defined as having difficulties walking, climbing stairs, grasping objects, bending, or standing for long periods of time. MEPS defines social limitations as whether a person has trouble participating in social or family activities because of a physical or cognitive impairment. A cognitive limitation exists if the person has trouble with memory, is easily confused, has trouble making decisions, or needs to be supervised for his or her own safety.
3–4
NEED HELP WITH ADL
1–20 5+
11%
3%1%0%
60
50
40
30
20
10
0
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
Figure 3.1. Functional, Physical, Social, and Cognitive Limitations, by Number of Chronic Conditions (2014)
WORK/HOME/SOCIAL LIMITATIONS
3–41–20 5+
42%
19%
6%
1%
60
50
40
30
20
10
0
3–4
PHYSICAL LIMITATIONS
1–20
60
50
40
30
20
10
5+0
51%
25%
9%
2%
NUMBER OF CHRONIC CONDITIONS
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
NEED HELP WITH INSTRUMENTAL ADL
3–41–20 5+
18%
6%2%0%
60
50
40
30
20
10
0
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
3–41–20 5+
23%
10%
3%1%
60
50
40
30
20
10
0
SOCIAL LIMITATIONS
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
NUMBER OF CHRONIC CONDITIONS
COGNITIVE LIMITATIONS
3–41–20 5+
23%
10%
4%1%
60
50
40
30
20
10
0
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
NUMBER OF CHRONIC CONDITIONS
NUMBER OF CHRONIC CONDITIONS NUMBER OF CHRONIC CONDITIONS NUMBER OF CHRONIC CONDITIONS
20
Older adults have more limitations on their daily activities and cognitive health than younger people.
Figure 3.2. ADL, Instrumental ADL, and Cognitive Limitations by Age and Number of Chronic
Conditions (2014)
INSTRUMENTAL ADL LIMITATIONS
3–41–20 5+
3–4
COGNITIVE LIMITATIONS
1–20
25
20
15
10
5
5+0
3–4
ADL LIMITATIONS
1–20 5+
25
20
15
10
5
0
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
NUMBER OF CHRONIC CONDITIONS
25
20
15
10
5
00%
2%
1%
5%
3%
4%
13%
9%
0%
3%
1%
7%
4%
9%
21%
14%
1%
4%3%
8%10%
10%
25%
21%
25 percent of adults under age 65 with five or more chronic conditions have cognitive limitations.
18–64 years
65 years and over
Age
CHAPTER 3 | Functional Status of Adults with Multiple Chronic Conditions | 20
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
NUMBER OF CHRONIC CONDITIONS NUMBER OF CHRONIC CONDITIONS
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
21
Appendix Detailed Methodology and Limitations
Data and Chronic Condition Identification
We used data from MEPS, a nationally representative
survey of U.S. health and health care use administered by
AHRQ.13 Most charts use data from 2014; charts that compare
the change in the treated prevalence of conditions over time
use data from 2008 through 2014. We use the term treated
prevalence to indicate that the data are survey-reported and
therefore may underestimate the true prevalence of a given
disease. Similar to previous chartbooks, we use the Clinical
Classification Software (CCS), which groups individual
ICD-9 codes into clinically distinct conditions, such as “essential
hypertension,” publicly available from the Healthcare Cost and
Utilization Project.14 Chronic conditions were identified with
Dr. Wenke Hwang’s publicly available Chronic Condition
Indicator, which was also used for previous chartbooks.6, 16, 21
In contrast with the previous chartbook, we did not group
together distinct CCS categories. Our results are similar
even without grouping together such categories as essential
hypertension (CCS 98) and hypertension with complications
(CCS 99). A complete listing of ICD-9 codes associated with
each CCS category is available from the Healthcare Cost and
Utilization Project: https://www.hcup-us.ahrq.gov/toolssoftware/
ccs/AppendixASingleDX.txt.
For each person, we assigned a chronic condition indicator for
the given CCS category if at least one of their ICD-9 codes in the
CCS category was labeled as chronic in the Chronic Condition
Indicator. This avoided overcounting multiple ICD-9s within the
same CCS category. For example, if a person had two ICD-9s
within the essential hypertension category (CCS 98), they were
only counted as having one chronic condition of hypertension.
Appendix | 21
22
Most of the ICD-9s within a given category for the top ten chronic
conditions are chronic in the CCI. There are a few, such as other
upper respiratory infections, that have a smaller proportion of
chronic ICD-9s within the CCS category.
Beginning in 2013, MEPS began masking certain three-digit
ICD-9 codes in the medical condition file to protect individuals
with rare conditions from possible identification. For a given
observation, the CCS code is available, but the ICD-9 codes
may be missing. The percentages of masked patient conditions
were 6.1 percent in 2013 and 9.2 percent in 2014, as compared
with less than 1 percent in 2012. The missing ICD-9s caused
drops in the prevalence of certain conditions in 2013 and 2014
compared with previous years, since we were identifying chronic
conditions from the ICD-9 level. While most CCS categories are
considered entirely chronic or non-chronic, the masking makes
it difficult to identify chronic conditions within CCS categories
that have a mix of chronic and non-chronic conditions. To impute
these masked conditions, we first calculated the percentage of
the CCS category that was considered chronic using historical
MEPS condition data from 2003 to 2012. We then used the
decision rules shown in Table A.1 to determine whether a
condition would be deemed chronic or non-chronic.
Appendix | 22
Table A.1. Decision Rules for Imputing Masked Conditions
Percentage of Cases Within the
CCS Category That Were Chronic
Conditions in 2003–2012
Number of CCS
Categories
Number of Observations
(2013)
Number of Observations
(2014)Decision
Rule
90–100% 37 2,573 2,651 Chronic
10.1–89.9% 30 612 1,108 Non-chronic
0–10% 76 3,909 6,477 Non-chronic
23
As a sensitivity analysis, we tested assigning the middle category
of cases (10.1 percent to 89.9 percent) to chronic instead of non-
chronic. Because of the relatively small sample size of this group,
the impact on our outcome measure of an individual’s number of
chronic conditions was small. For example, the percentage of the
population with at least one chronic condition in 2013 was
60.18 percent (if we assigned all middle cases to non-chronic)
and 60.45 percent (if we assigned all middle cases to chronic),
for a difference of just 0.27 percent. We set middle-category
cases to non-chronic to provide a conservative estimate
of chronic conditions. The decision rule for this set of CCS
categories was then applied across all years of data to ensure
the comparability of estimates from one year to the next.
Therefore, our estimates may differ slightly from the estimates
published in prior chartbooks. The list of CCS categories with
missing ICD-9 codes is available from the authors upon request.
Limitations
While MEPS is one of the best national sources of health care
spending and health status, it is important to highlight that it is
a survey. As such, the data are potentially biased, particularly
when it comes to underreporting health conditions. Because
MEPS is a survey, chronic conditions are self-identified;
therefore, prevalence estimates from MEPS represent the treated
prevalence of a disease, which may be lower than the actual
prevalence. As a result, there are notable differences between
the treated prevalence for a given condition and the actual
prevalence measure in datasets with a laboratory component,
such as the National Health and Nutrition Examination
Survey (NHANES). For example, the proportion of adults with
hypertension in NHANES is 29 percent (2011–2014) versus our
estimate of approximately 26 percent for men and women for
2014.22
Appendix | 23
24
Two other limitations of note: The first is that MEPS only surveys
civilian and noninstitutionalized Americans. As a result, we are
missing the treated prevalence of disease in these groups.
However, because the proportion of institutionalized adults
is small, this may not markedly affect results. The Medicare
Current Beneficiary Survey reports that approximately 3 percent
of beneficiaries were in a long-term care facility in 2013.17 The
second limitation is that MEPS likely underreports medical
spending by about 17.6 percent, compared with the National
Health Expenditures Accounts available from CMS, due to
differences in the populations covered and services that are
included in the totals and even in service category definitions.18
These limitations have been documented elsewhere by Bernard
et al. (2012),18 and we highlight them so that readers interpret our
results with caution.
As seen in Figure A.1, there is a marked uptick in the treated
prevalence of chronic conditions between 2006–2007 and 2007–
2008, likely caused by a change in the questionnaire at that time
to include a section on “priority conditions,” which directly asks
respondents if a doctor has ever told them that they have a given
disease. Previously, respondents would have had to volunteer
the information. For this reason, we have limited our comparisons
over time to 2008–2014.23
Appendix | 24
25
Figure A.1. Prevalence of Multiple Chronic Conditions (2003–2014)
PE
RC
EN
TAG
E O
F U
.S. A
DU
LTS
WIT
H M
ULT
IPL
E C
HR
ON
IC C
ON
DIT
ION
S90
2003
60
50
40
30
20
10
0
2004 2005 2006
80
70
YEAR
2007 2008 2009 2010 2011 2012 2013 2014
NOTE: This figure documents the prevalence of multiple chronic conditions (two or more) by age group. The trend lines break at 2007 to indicate that MEPS changed its approach to the chronic disease questions.
Comparison of the Trends in Chronic Disease in MEPS to Other Sources
Our estimates of the trend in chronic condition prevalence
are flat for the period 2008–2014. This is consistent with other
national datasets, notably the Medicare population from data
tables of chronic conditions for fee-for-service beneficiaries
from the Centers for Medicare & Medicaid Services (CMS) and
the National Health Interview Survey (NHIS), both of which are
publicly available (Figure A.2).24, 25 We did not examine particular
individuals over time to determine whether they experienced
more chronic conditions. While the prevalence has remained
stable over time, the absolute numbers may have increased—
particularly for older Americans, as the baby-boomer generation
becomes eligible for Medicare.
81%
50%
18%
Appendix | 25
65 years and older
45–64 years
18–44 years
26
Figure A.2. Prevalence of Multiple Chronic Conditions in Adults
Age 65 and Older, 2008–2013P
ER
CE
NTA
GE
OF
U.S
. AD
ULT
S A
GE
65
AN
D O
LD
ER
WIT
H M
ULT
IPL
E C
HR
ON
IC C
ON
DIT
ION
S 90
2008 2009 2010 2011 2012 2013
60
50
40
30
20
10
0
80
70
YEAR
SOURCE: Publicly available data on the prevalence of having two or more chronic conditions from NHIS, MEPS, and CMS for those age 65 and older.
81%
70%
66%
61%
Our estimates of the treated prevalence of disease are slightly
higher than the CMS estimates for the prevalence of multiple
chronic conditions for the population of those age 65 and older
and are higher than the NHIS estimates. The differences are
likely due to the number of chronic conditions included in the
counts. We used the full list of chronic conditions corresponding
to the granular CCS categories. The CMS analysis limits its
analysis to 19 conditions, and NHIS limits its analysis to ten.
Appendix | 26
MEPS
CMS, women
CMS, men
NHIS
27
References
References | 27
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