The prevalence of multiple chronic conditions among working-age adults has been steadily increasing, according to recent Centers for Medicare and Medicaid Services data. Individuals with MCCs are defined as having two or more concurrent chronic behavioral or physical health conditions, most commonly including hypertension, high cholesterol, diabetes, depression and obesity.
In 2017, the most recent year of available data, MCCs affect more than 60% of these individuals, disproportionately impacting low-wage workers and minorities. The greater prevalence of MCCs is likely due to a combination of factors, like healthcare access limitations, low health literacy and cultural beliefs and practices.
Thirty-three percent of benefits enrollees are in high-deductible health plans, while only 7% of employers with more than 50 employees have any type of wage-based benefits subsidy, according to the 2020 Kaiser Family Foundation Survey of Employer Health Plans. For economically disadvantaged employees, the combination of these two factors creates a real risk of underinsurance, meaning that individuals may spend 10% or more of their wages on healthcare.
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When faced with the choice of paying for rent, buying food or managing chronic conditions, many people will forgo recommended treatments in favor of ensuring safe housing and food for their families.
These individuals have received comparatively little attention in employer health benefits strategic planning. The combination of these factors and the demonstrated tendency for individuals with MCCs to have lengthy employment tenure – often delaying retirement – sets the employer stage for risk of multiple year, high-cost claimants.
What can employers do?
As a first step, employers should consider evaluating MCC prevalence when looking at healthcare claims, to characterize the distribution of illness burden within their benefits enrollees. Assessing the distribution of enrollees with 0-1, 2-4, and 5 or more MCCs and their associated annual healthcare expenditures can provide a high-level perspective. More detailed evaluation by race/ethnicity or income levels may highlight particular subpopulations where a more focused, MCC-based approach (rather than a single disease-specific approach) to condition management may be warranted.
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Give consideration to MCC-targeted offerings that align with program attributes recommended by the Agency for Healthcare Research and Quality. These include a holistic approach to care. Acknowledge that people with MCCs are more than just a collection of diseases. Ensure that patient preferences and values are assimilated in a patient-centered management approach. Additionally, consider each patient in the context of their relationships and social circumstances must be incorporated as part of the overall care management process.
Finally, include mental health resources as an integral part of the management solution, since depression and anxiety are prevalent comorbid conditions that may not have been recognized previously. This consideration is particularly important because unaddressed behavioral health concerns may exacerbate the challenges of managing physical health issues.
Sustained engagement is a vital component of effective programs. MCCs develop over years and consequently do not resolve quickly following program implementation. Attrition or drop-out rates in condition-specific disease management programs are often significant, so it is important to ask about the proportion of individuals that have sustained participation in the MCC program over the course of a year.
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In terms of outcomes, look for vendors that can provide quantitative data that is clinically significant, such as treatment to target clinical goals for diabetes or depression, improved well-being or reduced illness-related work absence.
Ask to see success rates among individuals in different race, ethnicity and socioeconomic subgroups, to know that programs are likely to have success among these disadvantaged populations.
Addressing disparities in care
There is a growing recognition that disparities in healthcare among racial/ethnic minorities and low-wage workers are a manifestation of institutionalized, yet generally overlooked discrimination. In increasing numbers, employers are becoming aware of these concerns and taking steps to address the identified issues, through changes in benefits offerings and design. Understanding and addressing the needs of individuals with MCC is likely to help, given the greater representation of low-income and racial, ethnic minorities in this subpopulation. Individuals with MCCs typically have sustained and disproportionately high healthcare costs, so there’s a good likelihood that interventions can yield improvements in health and reduced avoidable healthcare expenditures.
As employers look for meaningful solutions to addressing healthcare cost drivers, there’s no time like the present to thoughtfully evaluate and address the needs of the underserved population of individuals with multiple chronic conditions.
