U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
PDF Version: http://aspe.hhs.gov/daltcp/reports/2010/closerlook.pdf (51 PDF pages)
This report was prepared under contract #HHS-100-03-0027 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Lewin Group. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, John Drabek, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: John.Drabek@hhs.gov.
Controlling health care costs has become an enormous policy challenge.
In examining drivers behind health care costs, researchers have found that individuals with chronic conditions account for a significant amount of health care spending.
Statistics showing that one half of the U.S. population has at least one chronic condition and represents more than 80 percent of the health care spending fail to discriminate among those who place a particularly high burden on the health system.
This chartbook examines the combination of chronic conditions and functional limitations as a potentially better predictor of high health care utilization.
People with functional limitations and chronic conditions need more health care services and help with activities of daily living, placing heavy demands on service delivery, social supports, and public budgets.
Although nearly half of the persons living in the community have at least one chronic condition, less than a third of those with chronic conditions have any functional limitation.
As the chartbook details, the co-occurrence of chronic conditions and functional limitations has wide-reaching consequences for the health care system, individuals, and the economy. Providing individuals who have both chronic conditions and functional limitations with delivery of effective treatment and coordination across health care and social service systems may offer a high yield strategy to improve lives and control spending.
Data -- The analyses rely on the 2006 Medical Expenditures Panel Survey (MEPS) which represents the non-institutionalized U.S. population. Having only information on the non-institutionalized is an important limitation for studying chronic disease and disability spending because the nearly two million nursing facility residents not included in the analysis would add close to $200 billion to the $1.03 trillion represented by the population presented here. Health spending includes the following services: inpatient stays, physician offices or outpatient visits, emergency room visits, prescription drugs, and home health care.1
Chronic Conditions -- A chronic condition lasts or is expected to last 12 months or longer and either places limitations on normal functioning or requires ongoing care. The analysis relied on a list of 180 diagnosis classifications2 determined to be chronic by a panel of five internists for a prior study for the Agency for Healthcare Research and Quality (AHRQ).3 This analysis focuses on the conditions included in the list defined by AHRQ as chronic.4
Functional Limitations -- Limitation in one or more of the following:
Physical activity, such as difficulty walking, bending, or stooping.
Normal life activity, such as work, housework, or school.
Received assistance with Activities of Daily Living (ADL): bathing, eating, dressing, transferring (i.e., from bed to chair), toileting, and walking.
Received assistance with Instrumental Activities of Daily Living (IADL): doing housework, preparing meals, taking medications, shopping, telephoning, and managing money.
Top 5% of Spenders -- People who had health care expenditures greater than $14,600 in 2006 represented the top 5 percent of spenders.
 |
Fourteen percent of U.S. community residents had both chronic conditions and functional limitations. This 14 percent accounts for 46 percent of all health care spending.
Among the 42 million people with both a chronic condition and a functional limitation, 14 million also received help with an ADL or IADL. This 14 million represents 5 percent of the population and 23 percent of all spending.
Two percent of the population report functional limitations, including some receiving assistance with ADLs or IADLs, but no chronic conditions. Injuries and infections account for most of the non-chronic conditions among those with functional limitations only.
People with chronic conditions and functional limitations spent three times as much as people with only chronic conditions.
 |
People with chronic conditions who received help for their ADLs or IADLs spent much more than their counterparts with just chronic conditions. For example, among those with one chronic condition, people who received help with an ADL or IADL spent almost four times that of people with only one chronic condition ($8,942 versus $2,380 per person per year, respectively).
People who did not receive assistance with ADLs or IADLs, but still had some functional limitations, spent considerably more than people with chronic conditions only.
 |
On average, the 42 million people with chronic conditions and functional limitations spent at least three times the overall average annual health expenditures for all community residents ($11,284 versus $3,452). People with chronic conditions and functional limitations also spend three times what people who only have chronic conditions spend ($11,284 versus $3,641).
The subset of persons with chronic conditions and functional limitations that received help with ADLs or IADLs on average spent the most-$16,418 per person. This is almost five times the overall population average of $3,452.
Approximately 42 percent of spending for those with chronic conditions and who received help with ADLs or IADLs went to inpatient hospital care, suggesting that improved care management may yield savings in health care spending.
 |
People with chronic conditions and functional limitations had higher average spending across all payment sources.
People with a combination of chronic conditions and functional limitations faced higher out-of-pocket costs. They paid two to three times as much out-of-pocket as the overall population, $1,557 versus $654, but paid a smaller proportion of their total expenditures out-of-pocket (14 percent versus 19 percent). (See Appendix).
Public programs covered a large portion of expenditures for people who received help with ADLs and IADLs. On average, Medicare accounted for 48 percent of the group's annual expenditures and Medicaid covered 13 percent.
| Exhibit 5: Overview of Community Residents with Functional Limitations and Chronic Conditions by Age Groups, 2006 | ||||
|---|---|---|---|---|
| Number
of Community Residents (Millions) |
Percent of Age Group with Chronic Conditions & Functional Limitations |
Total Health Care Expenditures (Billions) |
Average Annual Health Care Expenditures |
|
| All Ages | 42 | 14% | $473 | $11,283 |
| Age 65 & Older | 18 | 48% | $235 | $12,880 |
| Under Age 65 | 24 | 9% | $239 | $10,068 |
| SOURCE: The Lewin Group analysis of 2006 Medical Expenditures Panel Survey, 2009 | ||||
The elderly have a higher prevalence rate of chronic conditions and functional limitations (48 percent of the elderly versus nine percent of the non-elderly).
However, the large size of the population under age 65 results in a greater number of non-elderly persons with chronic conditions and functional limitations. Most of the 42 million persons with chronic conditions and functional limitations were under age 65 (24 million, or 57 percent).
Total health care spending for the younger and older groups of persons with chronic conditions and functional limitations are similar, with $239 billion for the non-elderly and $235 billion for the elderly.
However, average annual health spending for those with chronic conditions and functional limitations is 28 percent higher among the elderly than among the non-elderly ($12,880 for the elderly and $10,068 for the non-elderly).
 |
Among individuals under age 65 with chronic conditions and functional limitations, 13 million had some private insurance, while 7 million had only public insurance.
Among older Americans with chronic conditions and functional limitations, dual eligibles spent the most on average ($14,172 per person per year). Dual eligibles spent more than those who used a combination of public and private insurance ($13,764 per person per year) or people who primarily used Medicare only ($11,083 per person per year).
| Exhibit 7: Most Common Conditions by Select Groups, 2006 | |||
|---|---|---|---|
| People with Chronic Conditions Only |
People
with Functional Limitations Only |
People with Chronic Conditions & Functional Limitations |
People with Chronic Conditions & Received ADL/IADL Help |
| Chronic Conditions | Conditions Not
Classified as Chronic by AHRQ |
Chronic Conditions | Chronic Conditions |
| Essential Hypertension | Back Disorder Nec & Nos | Essential Hypertension | Essential Hypertension |
| Allergic Rhinitis | Injury Nec/Nos | Dis of Lipoid Metabolism | Diabetes Mellitus |
| Dis of Lipoid Metabolism | Joint Disorder Nec & Nos | Arthropathies Nec/Nos | Dis of Lipoid Metabolism |
| Chronic Sinusitis | General Symptoms | Depressive Disorder Nec | Depressive Disorder Nec |
| Depressive Disorder Nec | Acute Nasopharyngitis | Diabetes Mellitus | Arthropathies Nec/Nox |
| Asthma | Other Intestinal Infection | Neurotic Disorders | Neurotic Disorders |
| Neurotic Disorders | Other Soft Tissue Dis | Allergic Rhinitis | Allergic Rhinitis |
| Diabetes Mellitus | Normal Pregnancy | Intervertebral Disc Dis | Ill-Defined Heart Disorder |
| Arthropathies Nec/Nos | Periph Enthesopathies | Asthma | Asthma |
| Migraine | Skin/Other Integument Symp | Ill-Defined Heart Disorder | Intervertebral Disc Dis |
| Acquired Hypothyroidism | Influenza | Chronic Sinusitis | Cataract |
| Hyperkinetic Syndrome | Sprain of Ankle & Foot | Cataract | Cardiac Dysrhythmias |
| Intervertebral Disc Disorder | Diseases of Esophagus | Cardiac Dysrhythmias | Acquired Hypothyroidism |
| Cataract | Sprain Of Knee & Leg | Acquired Hypothyroidism | Chronic Sinusitis |
| Ill-Defined Heart Disorder | Other Urinary Tract Disorder | Glaucoma | Heart Failure |
| SOURCE: The Lewin Group
analysis of 2006 Medical Expenditures Panel Survey, 2009 Dis: disorder; Nec: not elsewhere classified; Nos: not otherwise specified |
|||
Hypertension (high blood pressure) tops the chronic condition list for all groups with some chronic condition.
People with chronic conditions and functional limitations commonly had hypertension, diabetes, lipoid metabolism disorders (high cholesterol), and arthritis disorders.
Mental health conditions (depression and neurotic disorders) constituted two of the top ten chronic conditions among people with chronic conditions and functional limitations.
The chronic conditions of allergies, chronic sinusitis, and asthma were more frequent among those with chronic conditions only than among those with both chronic conditions and functional limitations.
 |
| Nec: not elsewhere classified; Nos: not otherwise specified |
About 44 percent of people under age 65 had a least one chronic condition (116 million out of 261 million).
About a quarter of people under age 65 with a chronic condition had hypertension (high blood pressure), and about a fifth had allergic rhinitis (allergies).
Other common chronic conditions included mood disorders (depression and affective psychoses) and lipoid metabolism disorders.
 |
| Nec: not elsewhere classified; Nos: not otherwise specified |
About 89 percent of people age 65 and over had a least one chronic condition (34 million out of 38 million).
About 60 percent of people age 65 and over with chronic conditions had hypertension (high blood pressure). About 40 percent had a lipoid metabolism disorder (high cholesterol). About a quarter had arthritis and nearly a quarter had diabetes.
Some conditions affected much larger percentages of people age 65 and over than people under age 65, such as arthropathies (arthritis), diabetes, hypertension and lipoid metabolism disorders.
 |
Overall, the group under age 65 with chronic conditions and functional limitations (24 million) accounted for $239 billion in health care expenditures. On average, people in this group spent $10,391 on health care in 2006.
Among people under age 65, the group with chronic conditions who received help with ADLs or IADLs had disproportionately high health expenditures: 3 percent of people accounted for 15 percent of all spending.
 |
The 18 million people age 65 and over with chronic conditions and functional limitations made up 6 percent of the all-ages community-based population and represented about a quarter of the nation's total health care spending ($235 billion out of $1.03 trillion).
The 20 percent of older adults with chronic conditions who received help with ADLs or IADLs represented 40 percent of all spending by community residents age 65 and over.
Older adults who had chronic conditions without functional limitations represented a relatively modest share of spending. The 42 percent with at least one chronic condition but no functional limitation accounted for 27 percent of spending for older adults.
 |
Within the $1.03 trillion in health care expenditures among the U.S. community population, spending is highly concentrated among a relatively small proportion of individuals.
Given the high concentration of medical expenditures incurred by the top 5 percent of the population ranked by health care spending, identifying the characteristics of these individuals is important for policy.
 |
People with functional limitations and chronic conditions were over four times as likely to be in the top 5 percent of spenders as the general population.
People with at least one chronic condition who received help with an ADL or IADL were over six times as likely to be in the top 5 percent of spenders as the general population. Number of people in each bar and details of relative risk can be found in the Appendix.
 |
People with chronic conditions who also received help with an ADL or IADL represented one-third of the top 5 percent of spenders and over a third of expenditures.
People in the top 5 percent of spenders with chronic conditions and, who received help with ADL or IADL, represent less than 2 percent of the overall community-based population, but represent 18 percent of all spending.
 |
| Nec: not elsewhere classified; Nos: not otherwise specified |
Top chronic conditions for those in the top 5 percent of spenders and the overall population were very similar-hypertension (high blood pressure), mood disorders (depression and affective psychoses), lipoid metabolism disorders, and diabetes.
However, chronic conditions were more prevalent among the top 5 percent of spenders than in the overall population under 65. For example, 24 percent of the overall population under age 65 had hypertension, as seen in Exhibit 8, but 42 percent of the top 5 percent under age 65 had hypertension.
 |
| Nec: not elsewhere classified; Nos: not otherwise specified |
Two-thirds of older adults in the top 5 percent of spenders had hypertension (high blood pressure), and almost half had a lipoid metabolism disorder (high cholesterol).
While chronic conditions were important for high health care spenders in both age groups, the conditions affected much larger percentages of people age 65 and over. For example, 66 percent of older top-tier spenders reported hypertension, while 42 percent of the younger group reported hypertension.
 |
On average, individuals in the top 5 percent spent ten times more than the general population on health care services ($32,942 versus $3,452).
People who received help with ADLs or IADLs and had chronic conditions spent nearly three times the average home health expenditures as the overall top 5 percent group ($4,611 versus $1,750, see Appendix).
On average, people with chronic conditions and functional limitations represent the higher spending among highest spenders. The 95th percentile of health care expenditures, the threshold for the top 5 percent of spenders group, was $14,600. However, the top 5 percent spenders with both functional limitations and chronic conditions spent an average of $35,087 on health care in 2006.
 |
Among the nine million community residents with both chronic conditions and functional limitations who spent at least $14,600 in health care in 2006, individuals under age 65 relied more heavily on private insurance than public insurance.
Among the primary insurance groups for older adults in the top 5 percent with both chronic conditions and functional limitations, Medicare covered between $24,000 and $28,000 in 2006.
 |
Older dual eligibles in the top 5 percent with both chronic conditions and functional limitations spent an average of $8,516 a year on home health, two to three times the amount that older adults in other insurance categories spent. The older dual eligibles also had lower expenditures for outpatient and inpatient care compared to other older adults of different coverage types.
Among people under age 65 in the top 5 percent with both chronic conditions and functional limitations, people with public insurance only spent on average over three times as much on home health as people with some private insurance ($3,502 versus $1,040).
| Exhibit 20: Overview of Dual Eligibles in the Community, 2006 | |||||
|---|---|---|---|---|---|
| Number of Dual Eligibles in Community (Millions) |
Percent
of Total Community Population |
Total Health Care Expenditures (Billions) |
Percent of Total Health Care Expenditures |
Average Annual Health Care Expenditures |
|
| All Dual Eligibles | 7.0 | 2.3% | $70 | 7% | $10,133 |
| Dual Eligibles with Chronic Conditions and Functional Limitations | 4.4 | 1.5% | $60 | 6% | $13,821 |
| Age 65 & Older | 2.6 | 0.6% | $37 | 4% | $14,173 |
| Under Age 65 | 1.7 | 0.9% | $23 | 2% | $13,288 |
| SOURCE: The Lewin Group analysis of 2006 Medical Expenditures Panel Survey, 2009 | |||||
In 2006, seven million people living in the community had both Medicare and Medicaid coverage. Among them, 63 percent had both chronic conditions and functional limitations.
Dual eligibles in the community spent $70.3 billion on health care in 2006. On average, dual eligibles spent $10,133 on health care, compared to $3,452 annual health care expenditure for the community-based population at the national level.
Dual eligibles with chronic conditions and functional limitations represented about 1.5 percent of the community-based population, and with $60.5 billion in total expenditures, represented 6 percent of the nation's spending.
On average, dual eligibles with chronic conditions and functional limitations spent $13,821 on health care in 2006. About 28 percent of this group is in the top 5 percent of spenders, meaning that dual eligibles with chronic conditions and functional limitations were over five times as likely to be in the top 5 percent of spenders as the general population.
Many dual eligibles with chronic conditions and functional limitations were younger- 1.7 million were under the age of 65, making up 39 percent of all dual eligibles with chronic conditions and functional limitations.
On average, older dual eligibles with chronic conditions and functional limitations spent $14,173 on health care a year, close to the 95th percentile of health care spending ($14,600).
 |
Overall, dual eligibles spent $10,133 on health care and dual eligibles with chronic conditions and functional limitations spent $13,821. The national average for health care spending among the general population was $3,452.
Younger dual eligibles with chronic conditions and functional limitations spent almost twice as much on home health ($2,240) than the overall younger dual eligibles group ($1,395).
People with functional limitations and chronic conditions need more health care services and help with activities of daily living, placing heavy demands on service delivery, social supports, and public budgets.
Functional limitations, ADLs, and IADLs, in combination with chronic conditions, appear to serve as a more promising indicator than chronic conditions alone for the small group of individuals with a heavy concentration of health care spending.
Some Key Findings from this Chartbook:
People with both chronic conditions and functional limitations who received help with an ADL or IADL represented 5 percent of the population and 23 percent of all spending. This group spent at least four times the overall average annual health expenditures for all community residents.
People under age 65 with chronic conditions and functional limitations represent nine percent of younger adults but account for one-third of health care expenditures for the group.
Almost half of older adults had chronic conditions and functional limitations and accounted for over two-thirds of all health spending for that age group.
Among those with one chronic condition, people who received help with ADLs or IADLs spent almost four times what people with only one chronic condition spent.
Those with chronic conditions and who received help with ADLs or IADLs spent nearly $2,000 on home health, about 19 times the overall average.
People with at least one chronic condition who received help with ADLs or IADLs were over six times as likely to be in the top 5 percent of spenders as the general population.
The $493 billion spent on health care by 5 percent of the U.S. population represented half of health care spending by the entire community-based population in 2006 ($1 trillion). Among the top 5 percent of spenders, a majority-61 percent-had a chronic condition and functional limitation, which represented 64 percent of spending.
Among the top 5 percent of spenders, people with chronic conditions and functional limitations spent more on prescription drugs and home health.
Most dual eligibles had chronic conditions and functional limitations, and correspondingly higher expenditures.
The data presented here support continued study of emerging new models to better manage chronic conditions and functional limitations, as well as other strategies to prevent or delay functional limitation among those with chronic conditions only.
Appendix Each table in this Appendix provides data used in developing the corresponding figure or chart in the report. For example, Exhibit A-3 provides the amounts paid for each type of service listed in the bar chart Exhibit 3.
| Exhibit A-1: Distribution of Community Residents and Health Care Spending by Select Groups, 2006 | ||
|---|---|---|
| Health Status | Community Residents (Millions) |
Percent of Total People |
| No Chronic, No Limitation | 143.3 | 48% |
| Chronic Only | 108.5 | 36% |
| Functional Limitation Only | 5.5 | 2% |
| Chronic and Functional Limitation | 42 | 14% |
| Among Chronic Condition and Functional Limitation | Community
Residents (Millions) |
Percent of Total People |
| Received ADL-IADL Help | 14.3 | 5% |
| Had Other Functional Limitations Only | 27.6 | 9% |
| Total | 299.3 | 100% |
| Expenditures | Total
Spending (Billions) |
Percent of Total Spending |
| No Chronic, No Limitation | $ 146.4 | 14% |
| Chronic Only | $ 395.1 | 38% |
| Functional Limitation Only | $ 18.1 | 2% |
| Chronic and Functional Limitation | $ 473.4 | 46% |
| Among Chronic Conditions and Functional Limitation | Total
Spending (Billions) |
Percent of Total Spending |
| Received ADL-IADL Help | $ 235.7 | 23% |
| Had Other Functional Limitations Only | $ 237.8 | 23% |
| Total | $ 1,033 | 100% |
| Exhibit A-2: Average Annual Health Spending by Number of Chronic Conditions & Functional Limitations or ADLs/IADLs, 2006 | |||
|---|---|---|---|
| Number of Chronic Conditions | No
Functional Limitation |
Had
Other Functional Limitation Only |
Received Help with an ADL/IADL |
| No Chronic Condition | $ 1,022 | $ 2,672 | $ 5,287 |
| 1 Chronic Condition | $ 2,380 | $ 4,974 | $ 8,942 |
| 2 Chronic Conditions | $ 3,817 | $ 6,383 | $ 12,233 |
| 3 Chronic Conditions | $ 4,976 | $ 8,612 | $ 14,296 |
| 4 Chronic Conditions | $ 6,416 | $ 9,401 | $ 16,016 |
| 5+ Chronic Conditions | $ 9,723 | $ 12,749 | $22,380 |
| Exhibit A-3: Average Spending by Type of Service for Select Groups, 2006 | ||||||
|---|---|---|---|---|---|---|
| Health Services |
Everyone | Functional Limitation Only |
Chronic Condition Only |
No Functional Limitatoin, No Chronic Condition |
All Functional Limitation & Chronic Condition |
Subset
of Functional Limitation & Chronic --People who Received ADL/IADL Help |
| Outpatient | $ 1,117 | $ 1,168 | $ 1,349 | $ 365 | $ 3,079 | $ 3,464 |
| Inpatient | $ 1,027 | $ 1,298 | $ 843 | $ 288 | $3,989 | $ 6,870 |
| Emergency Room | $ 125 | $ 142 | $ 128 | $ 71 | $ 304 | $ 436 |
| Prescription Drugs | $ 746 | $ 230 | $ 893 | $ 69 | $ 2,746 | $ 3,286 |
| Home Health | $ 113 | $ 104 | $ 22 | $ 4 | $ 723 | $ 1,909 |
| Average Total Expenditures | $ 3,452 | $ 3,278 | $ 3,641 | $ 1,022 | $ 11,284 | $ 16,418 |
| Health Services |
Millions
of Community Residents, Everyone |
Millions
of Community Residents, Functional Limitation Only |
Millions
of Community Residents, Chronic Condition Only |
Millions
of Community Residents, No Functional Limitatoin, No Chronic Condition |
Millions
of Community Residents, All Functional Limitation & Chronic Condition |
Millions
of Community Residents, Subset of Functional Limitation & Chronic --People who Received ADL/IADL Help |
| Community Residents (Millions) | 299.3 | 5.5 | 108.5 | 143.3 | 42.0 | 14.3 |
| Percent
of Total Spending, Everyone |
Percent
of Total Spending, Functional Limitation Only |
Percent
of Total Spending, Chronic Condition Only |
Percent
of Total Spending, No Functional Limitatoin, No Chronic Condition |
Percent
of Total Spending, All Functional Limitation & Chronic Condition |
Percent
of Total Spending, Subset of Functional Limitation & Chronic --People who Received ADL/IADL Help |
|
| Percent of Total Spending | 100% | 2% | 38% | 14% | 46% | 23% |
| Exhibit A-4: Health Spending by Source of Financing for Select Groups, 2006 | ||||||
|---|---|---|---|---|---|---|
| Payment Source | Everyone | Functional Limitation Only |
Chronic Condition Only |
No Functional Limitatoin, No Chronic Condition |
All Functional Limitation & Chronic Condition |
Subset
of Functional Limitation & Chronic --People who Received ADL/IADL Help |
| Medicaid Expenditures | $ 299 | $ 453 | $ 200 | $ 132 | $ 1,107 | $ 2,100 |
| Medicare Expenditures | $ 812 | $ 581 | $ 471 | $ 13 | $ 4,456 | $ 7,853 |
| Private Insurance Expenditures | $ 1,408 | $ 1,323 | $ 1,889 | $ 564 | $ 3,061 | $ 3,601 |
| Out-of-Pocket Expenditures | $ 654 | $ 525 | $ 860 | $ 239 | $ 1,557 | $ 1,831 |
| Other Payment | $ 278 | $ 396 | $ 221 | $ 74 | $ 1,103 | $ 1,032 |
| Average Total Expenditures | $ 3,452 | $ 3,278 | $ 3,641 | $ 1,022 | $ 11,284 | $ 16,418 |
| Payment Sources | Millions
of Community Residents, Everyone |
Millions
of Community Residents, Functional Limitation Only |
Millions
of Community Residents, Chronic Condition Only |
Millions
of Community Residents, No Functional Limitatoin, No Chronic Condition |
Millions
of Community Residents, All Functional Limitation & Chronic Condition |
Millions
of Community Residents, Subset of Functional Limitation & Chronic --People who Received ADL/IADL Help |
| Community Residents (Millions) | 299.3 | 5.5 | 108.5 | 143.3 | 42.0 | 14.3 |
| Percent
of Total Spending, Everyone |
Percent
of Total Spending, Functional Limitation Only |
Percent
of Total Spending, Chronic Condition Only |
Percent
of Total Spending, No Functional Limitatoin, No Chronic Condition |
Percent
of Total Spending, All Functional Limitation & Chronic Condition |
Percent
of Total Spending, Subset of Functional Limitation & Chronic --People who Received ADL/IADL Help |
|
| Percent of Total Spending | 100% | 2% | 38% | 14% | 46% | 23% |
| Exhibit A-6: Health Spending by Primary Source of Insurance and Payment Source Among Community Residents with Chronic Conditions & Functional Limitations, 2006 | ||||||
|---|---|---|---|---|---|---|
| Payment Source |
Under
Age 65, Any Private |
Under
Age 65, Public Only |
All
Age, Uninsured |
Age
65+, Medicare & Privatea |
Age
65+, Medicare & Medicaid |
Age
65+, Medicare Only |
| Medicaid | $ 203 | $ 5,112 | --- | $ 173 | $ 2,646 | --- |
| Medicare | $ 929 | $ 3,311 | --- | $ 8,185 | $ 10,213 | $ 7,637 |
| Private | $ 7,746 | --- | --- | $ 2,578 | $ 132 | --- |
| Out-of-Pocket | $ 1,747 | $ 971 | $ 1,643 | $ 1,808 | $ 808 | $ 1,755 |
| Other | $ 849 | $ 884 | $ 2,310 | $ 1,020 | $ 373 | $ 1,691 |
| Average Total Expenditures | $ 11,474 | $ 10,278 | $ 3,953 | $ 13,764 | $ 14,172 | $ 11,083 |
| Millions
of Community Residents, Under Age 65, Any Private |
Millions
of Community Residents, Under Age 65, Public Only |
Millions
of Community Residents, All Age, Uninsured |
Millions
of Community Residents, Age 65+, Medicare & Private |
Millions
of Community Residents, Age 65+, Medicare & Medicaid |
Millions
of Community Residents, Age 65+, Medicare Only |
|
| Community Residents (Millions) | 13 | 7 | 3 | 10 | 3 | 6 |
| Percent
of Total Spending, Under Age 65, Any Private |
Percent
of Total Spending, Under Age 65, Public Only |
Percent
of Total Spending, All Age, Uninsured |
Percent
of Total Spending, Age 65+, Medicare & Private |
Percent
of Total Spending, Age 65+, Medicare & Medicaid |
Percent
of Total Spending, Age 65+, Medicare Only |
|
| Percent of Total Spending For those With Chronic Conditions and Functional Limitations | 31% | 17% | 7% | 24% | 7% | 14% |
|
||||||
| Exhibit A-8: Most Common Conditions Among Community Residents Under Age 65 with At Least One Chronic Condition, 2006 | |
|---|---|
| Under Age 65 | Percent of People with Condition, Out of 116 Million Community Residents with Some Chronic Condition |
| Disorder of Menstruation | 2% |
| Menopausal Disorders | 2% |
| Acquired Hypothyroidism | 4% |
| Hyperkinetic Syndrome | 4% |
| Intervertebral Disc Disorder | 5% |
| Migraine | 6% |
| Arthropathies Nec/Nos | 8% |
| Diabetes Mellitus | 10% |
| Neurotic Disorders | 12% |
| Asthma | 13% |
| Chronic Sinusitis | 13% |
| Disorder of Lipoid Metabolism | 16% |
| Mood Disorder | 19% |
| Allergic Rhinitis | 21% |
| Essential Hypertension | 24% |
| Mood Disorders is
comprised of people with Depressive Disorders Nec and Affective
Psychoses. Total number of community residents under age 65 is 261 M. |
|
| Exhibit A-9: Most Common Conditions Among Community Residents Age 65 and Over, 2006 | |
|---|---|
| Age 65 & Over | Percent of People with Condition, Out of 34 Million Community Residents with Some Chronic Condition |
| Chronic Sinusitis | 5% |
| Hearing Loss | 5% |
| Asthma | 6% |
| Acquired Hypothyroidism | 7% |
| Glaucoma | 7% |
| Cardiac Dysrhythmias | 9% |
| Neurotic Disorders | 9% |
| Allergic Rhinitis | 11% |
| Ill-Defined Heart Disorder | 11% |
| Cataract | 12% |
| Mood Disorders | 13% |
| Diabetes Mellitus | 23% |
| Arthropathies Nec/Nos | 25% |
| Disorder of Lipoid Metabolism | 41% |
| Essential Hypertension | 61% |
| Mood Disorders is
comprised of people with Depressive Disorders Nec and Affective
Psychoses. Total number of community residents age 65 and over is 38 M. |
|
| Exhibit A-10: Distribution of Community Residents Under Age 65 and Health Care Spending by Select Groups, 2006 | ||
|---|---|---|
| Health Status | Community Residents (Millions) |
Percent of Total People |
| No Chronic, No Limitation | 140.4 | 54% |
| Chronic Only | 92.4 | 35% |
| Functional Limitation Only | 4.7 | 2% |
| Chronic and Functional Limitation | 23.7 | 9% |
| Among Chronic Condition and Functional Limitation | Community
Residents (Millions) |
Percent of Total People |
| Received ADL-IADL Help | 6.6 | 3% |
| Had Other Functional Limitations Only | 17.1 | 7% |
| Total | 261.2 | 100% |
| Expenditures | Total
Spending (Billions) |
Percent of Total Spending |
| No Chronic, No Limitation | $ 142.8 | 20% |
| Chronic Only | $ 304.1 | 43% |
| Functional Limitation Only | $ 14.1 | 2% |
| Chronic and Functional Limitation | $ 238.7 | 35% |
| Among Chronic Conditions and Functional Limitation | Total
Spending (Billions) |
Percent of Total Spending |
| Received ADL-IADL Help | $ 101.8 | 15% |
| Had Other Functional Limitations Only | $ 136.9 | 20% |
| Total | $ 699.7 | 100% |
| Exhibit A-11: Distribution of Community Residents Age 65 and Over and Health Care Spending by Select Groups, 2006 | ||
|---|---|---|
| Health Status | Community Residents (Millions) |
Percent of Total People |
| No Chronic, No Limitation | 2.9 | 8% |
| Chronic Only | 16.1 | 42% |
| Functional Limitation Only | 0.8 | 2% |
| Chronic and Functional Limitation | 18.2 | 48% |
| Among Chronic Condition and Functional Limitation | Community
Residents (Millions) |
Percent
of Total People |
| Received ADL-IADL Help | 7.7 | 20% |
| Had Other Functional Limitations Only | 10.5 | 28% |
| Total | 38.0 | 100% |
| Expenditures | Total
Spending (Billions) |
Percent of Total Spending |
| No Chronic, No Limitation | $ 3.6 | 1% |
| Chronic Only | $ 91.0 | 27% |
| Functional Limitation Only | $ 4.0 | 1% |
| Chronic and Functional Limitation | $ 234.7 | 70% |
| Among Chronic Conditions and Functional Limitation | Total
Spending (Billions) |
Percent
of Total Spending |
| Received ADL-IADL Help | $ 133.9 | 40% |
| Had Other Functional Limitations Only | $ 100.8 | 30% |
| Total | $ 333.4 | 100% |
| Exhibit A-12: Distribution of Health Care Spending by Top 5% of Spenders Versus Those Not in the Top 5% Spenders, 2006 | ||
|---|---|---|
| Spending Status | Community Residents (Millions) |
Percent of Total People |
| Not Top 5% | 284.3 | 95% |
| Top 5% | 15.0 | 5% |
| Total | 299.3 | 100% |
| Expenditures | Total
Spending (Billions) |
Percent of Total Spending |
| Not Top 5% | $ 539.9 | 52% |
| Top 5% | $ 493.2 | 48% |
| Total | $ 1,033.1 | 100% |
| Exhibit A-13: Relative Risk of Being in the Top 5% of Health Care Spenders by Selected Groups, 2006 | |||
|---|---|---|---|
| Group
(By Chronic Condition, Functional Limitation) |
Community Residents in the Top 5% of Spenders (Millions) |
Percent of Group in Top 5% of Spenders |
Relative Probability of Being in the Top 5% |
| All Community Residents | 15.0 | 5% | 1.0 |
| No Chronic Condition, No Functional Limitation | 1.1 | 1% | 0.2 |
| Chronic Condition Only | 4.6 | 4% | 0.8 |
| Functional Limitation Only | 0.2 | 4% | 0.8 |
| 1+ Chronic Conditions | 13.6 | 9% | 1.8 |
| 2+ Chronic Conditions | 11.5 | 13% | 2.7 |
| 3+ Chronic Conditions | 9.3 | 18% | 3.6 |
| Chronic Conditions and Functional Limitation | 9.0 | 21% | 4.3 |
| Help with an ADL/IADL | 4.8 | 31% | 6.1 |
| Help with an ADL/IADL and 1+ Chronic Conditions | 4.7 | 33% | 6.6 |
| Help with an ADL/IADL and 2+ Chronic Conditions | 4.4 | 36% | 7.1 |
| Help with an ADL/IADL and 3+ Chronic Conditions | 3.8 | 38% | 7.7 |
| NOTE: Relative risk for being in the top 5% of spenders is the probability that a specified group will be in the top 5%, compared to the overall probability of being in the top 5% of spenders. | |||
| Exhibit A-14: Distribution of Community Residents and Health Care Spending Among the Top 5% of Spenders by Select Groups, 2006 | ||
|---|---|---|
| Health Status | Community Residents (Millions) |
Percent of Total People |
| No Chronic Condition, No Functional Limitation | 1.1 | 7% |
| Chronic Condition Only | 4.6 | 31% |
| Functional Limitation Only | 0.2 | 1% |
| Chronic Condition and Functional Limitation | 9.0 | 61% |
| Among Chronic Condition and Functional Limitation | Community
Residents (Millions) |
Percent of Total People |
| Received ADL-IADL Help | 4.7 | 32% |
| Had Other Functional Limitations Only | 4.3 | 29% |
| Total | 15 | 100% |
| Expenditures | Total
Spending (Billions) |
Percent of Total Spending |
| No Chronic Condition, No Functional Limitation | $ 30.3 | 6% |
| Chronic Condition Only | $ 137.9 | 28% |
| Functional Limitation Only | $ 8.6 | 2% |
| Chronic Condition and Functional Limitation | $ 316.3 | 64% |
| Among Chronic Conditions and Functional Limitation | Total
Spending (Billions) |
Percent of Total Spending |
| Received ADL-IADL Help | $ 181.8 | 37% |
| Had Other Functional Limitations Only | $ 134.5 | 27% |
| Total | $ 493.2 | 100% |
| Exhibit A-15: Most Common Chronic Diseases Among Top 5% of Spenders Under Age 65, 2006 | |
|---|---|
| Community Residents Under Age 65 | Percent of People with Condition, Out of 7.7 Million Community Residents with Some Chronic Condition |
| Malignant Neoplasm of Female Breast | 5% |
| Cardiac Dysrhythmias | 6% |
| Ill-Defined Heart Disease | 6% |
| Acquired Hypothyroidism | 7% |
| Migraine | 7% |
| Intervertebral Disc Disorder | 11% |
| Asthama | 12% |
| Chronic Sinusitis | 12% |
| Arthropathies Nec/Nos | 17% |
| Neurotic Disorders | 17% |
| Allergic Rhinitis | 20% |
| Diabetes Mellitus | 25% |
| Disorder of Lipoid Metabolism | 29% |
| Mood Disorder | 31% |
| Essential Hypertension | 42% |
| Mood Disorders is
comprised of people with Depressive Disorders Nec and Affective
Psychoses. Total number of community residents in the top 5% of spenders under age 65 is 9 M. |
|
| Exhibit A-16: Most Common Conditions Among Top 5% of Spenders Age 65 and Over, 2006 | |
|---|---|
| Community Residents Age 65 & Over | Percent of People with Condition, Out of 6 Million Community Residents with Some Chronic Condition |
| Arterial Embolism | 7% |
| Cerebral Vascular Accident | 8% |
| Glaucoma | 8% |
| Asthma | 10% |
| Heart Failure | 11% |
| Allergic Rhinitis | 13% |
| Cataract | 13% |
| Cardiac Dysrhythmias | 14% |
| Neurotic Disorder | 15% |
| Mood Disorders | 19% |
| Ill-Defined Heart Disease | 20% |
| Arthropathies Nec/Nos | 30% |
| Diabetes Mellitus | 37% |
| Disorder of Lipoid Metabolism | 45% |
| Essential Hypertension | 66% |
| Mood Disorders is
comprised of people with Depressive Disorders Nec and Affective
Psychoses. Total number of community residents in the top 5% of spenders age 65 and over is 6 M. |
|
| Exhibit A-17: Health Care Spending by Type of Service Among the Top 5% of Spenders, 2006 | ||||||
|---|---|---|---|---|---|---|
| Top 5% of Spenders |
Functional Limitation Only |
Chronic Condition Only |
No Functional Limitatoin, No Chronic Condition |
Functional Limitation & Chronic Condition |
Subset
of Functional Limitation & Chronic --People who Received ADL/IADL Help |
|
| Outpatient | $ 8,363 | $ 8,562 | $ 9,324 | $ 6,555 | $ 8,100 | $ 7,305 |
| Inpatient | $ 16,628 | $ 25,629 | $ 15,602 | $ 16,694 | $ 16,919 | $ 19,462 |
| Emergency Room | $ 767 | $ 376 | $ 704 | $ 899 | $ 792 | $ 885 |
| Prescription Drugs | $ 4,630 | $ 1,892 | $ 3,101 | $ 1,132 | $ 5,920 | $ 5,608 |
| Home Health | $ 1,750 | $ 1,375 | $ 394 | $ 288 | $ 2,636 | $ 4,611 |
| Average Total Expenditures | $ 32,942 | $ 38,768 | $ 30,076 | $ 26,419 | $ 35,087 | $ 38,518 |
| Millions
of Community Residents, Top 5% of Spenders |
Community Residents, Top 5% of Spenders, Functional Limitation Only |
Community Residents, Top 5% of Spenders, Chronic Condition Only |
Community Residents, Top 5% of Spenders, No Functional Limitatoin, No Chronic Condition |
Community Residents, Top 5% of Spenders, Functional Limitation & Chronic Condition |
Community Residents, Top 5% of Spenders, Subset of Functional Limitation & Chronic --People who Received ADL/IADL Help |
|
| Community Residents (Millions) | 15.0 | 0.2 | 4.6 | 1.1 | 9.0 | 4.7 |
| Percent
of Total Spending for Top 5% |
Percent
of Total Spending for Top 5% Functional Limitation Only |
Percent
of Total Spending for Top 5% Chronic Condition Only |
Percent
of Total Spending for Top 5% No Functional Limitatoin, No Chronic |
Percent
of Total Spending for Top 5% Functional & Chronic |
Percent
of Total Spending for Top 5% Subset of Functional & Chronic Received ADL/IADL Help |
|
| Percent of Total Spending | 100% | 2% | 28% | 6% | 64% | 37% |
| Exhibit A-18: Average Health Spending for Community Residents with Chronic Conditions and Functional Limitations by Primary Source of Insurance and Payments Source Among the Top 5% of Spenders, 2006 | ||||||
|---|---|---|---|---|---|---|
| Insurance Payment |
Under
Age 65 Any Private |
Under
Age 65 Public Only |
All
Ages Uninsured |
Age
65+ Medicare & Private |
Age
65+ Medicare & Medicaid |
Age
65+ Medicare Only |
| Medicaid | $ 736 | $ 15,065 | $ 0 | $ 616 | $ 7,192 | $ 0 |
| Medicare | $ 3,808 | $ 10,963 | $ 0 | $ 23,447 | $ 27,921 | $ 24,196 |
| Private | $ 27,185 | $ 0 | $ 0 | $ 6,307 | $ 373 | $ 0 |
| Self | $ 4,007 | $ 2,111 | $ 4,489 | $ 2,918 | $ 1,302 | $ 3,145 |
| Other | $ 2,726 | $ 2,522 | $ 19,408 | $ 2,794 | $ 871 | $ 5,508 |
| Average Total Expenditures | $ 38,461 | $ 30,660 | $ 23,898 | $ 36,081 | $ 37,659 | $ 32,849 |
| Millions
of Community Residents, Under Age 65 Any Private |
Millions
of Community Residents, Under Age 65 Public Only |
Millions
of Community Residents, All Age Uninsured |
Millions
of Community Residents, Age 65+ Medicare & Private |
Millions
of Community Residents, Age 65+ Medicare & Medicaid |
Millions
of Community Residents, Age 65+ Medicare Only |
|
| Community Residents (Millions) | 2.7 | 1.5 | 0.2 | 2.7 | 0.7 | 1.3 |
| Percent
of Top 5%, Under Age 65 Any Private |
Percent
of Top 5%, Under Age 65 Public Only |
Percent
of Top 5%, All Ages Uninsured |
Percent
of Top 5%, Age 65+ Medicare & Private |
Percent
of Top 5%, Age 65+ Medicare & Medicaid |
Percent
of Top 5%, Age 65+ Medicare Only |
|
| Percent of Top 5% with Chronic Conditions & Functional Limitations | 30% | 16% | 2% | 29% | 8% | 14% |
| Exhibit A-19: Health Spending by Type of Service for the Top 5% by Primary Insurance, 2006 | ||||||
|---|---|---|---|---|---|---|
| Health
Services Settings |
Under Age 65, Any Private |
Under Age 65, Public Only |
All
Age, Uninsured |
Over
Age 65, Medicare & Private |
Over Age 65, Dual Eligible |
Over
Age 65, Medicare Only |
| Outpatient | $ 11,602 | $ 6,930 | $ 5,230 | $ 7,245 | $ 5,085 | $ 6,039 |
| Inpatient | $ 15,587 | $ 12,333 | $ 13,252 | $ 19,266 | $ 18,025 | $ 19,114 |
| Emergency Room | $ 937 | $ 837 | $ 855 | $ 725 | $ 1,071 | $ 653 |
| Prescription Drugs | $ 8,489 | $ 6,666 | $ 4,094 | $ 4,545 | $ 4,535 | $ 3,729 |
| Home Health | $ 1,040 | $ 3,502 | $ 94 | $ 3,146 | $ 8,516 | $ 2,518 |
| Average Total Expenditures | $ 38,461 | $ 30,660 | $ 23,898 | $ 35,816 | $ 37,659 | $ 32,849 |
| Exhibit A-21: Health Spending by Type of Service for Dual Eligibles in the Community by Select Groups, 2006 | ||||||
|---|---|---|---|---|---|---|
| Health Services Settings |
All Ages | Under Age 65 | Age 65 & Over | |||
| All Groups | Chronic Conditions & Functional Limitations |
All Groups | Chronic Conditions & Functional Limitations |
All Groups | Chronic Conditions & Functional Limitations |
|
| Office/Outpatient ($) | 1,841 | 2,540 | 1,992 | 2,846 | 1,736 | 2,338 |
| Inpatient ($) | 3,480 | 4,459 | 2,355 | 3,206 | 4,256 | 5,288 |
| Emergency Room ($) | 290 | 403 | 282 | 379 | 296 | 420 |
| Prescription Drugs ($) | 2,543 | 3,451 | 2,831 | 4,218 | 2,344 | 2,944 |
| Home Health ($) | 1,700 | 2,589 | 1,395 | 2,240 | 1,910 | 2,820 |
| Average Total Expenditures ($) | 10,133 | 13,821 | 9,146 | 13,288 | 10,814 | 14,173 |
| Millions
of Community Residents, All Ages & Groups |
Millions
of Community Residents, All Ages with Chronic & Functional |
Millions
of Community Residents, Under Age 65 & All Groups |
Millions
of Community Residents, Under Age 65 with Chronic & Functional |
Millions
of Community Residents, Age 65 & Over, All Groups |
Millions
of Community Residents, Age 65 & Over with Chronic & Functional |
|
| Community Residents (Millions) | 6.9 | 4.4 | 2.8 | 1.7 | 4.1 | 2.6 |
| Percent
of Total Spending for Dual Eligibles, All Ages & Groups |
Percent
of Total Spending for Dual Eligibles, All Ages with Chronic & Functional |
Percent
of Total Spending for Dual Eligibles, Under Age 65 & All Groups |
Percent
of Total Spending for Dual Eligibles, Under Age 65 with Chronic & Functional |
Percent
of Total Spending for Dual Eligibles, Age 65 & Over, All Groups |
Percent
of Total Spending for Dual Eligibles, Age 65 & Over with Chronic & Functional |
|
| Percent of Total Spending for Dual Eligibles (%) | 100 | 86 | 37 | 33 | 63 | 53 |
MEPS may miss some expenditures for high-cost cases while people are living in the community due to sample attrition. For further information see: Sing, Merrile, Jessica S. Banthin, Thomas M. Selden, Cathy A. Cowan and Sean P. Keehan, "Reconciling Medical Expenditure Estimates from the MEPS and NHEA, 2002," Health Care Financing Review 28, no. 1:25-40.
Diagnosis classification can be defined by 3-digit International Classification of Diseases codes (ICD-9).
URL: http://www.hcup-us.ahrq.gov/toolssoftware/chronic/chronic.jsp#files
Hwang, W., Heller, W., Ireys, H., Anderson, G. 2001. "Out-Of-Pocket Medical Spending for Care of Chronic Conditions," Health Affairs 20, no. 6:267-278.
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