If we build it, who will come? Working-age adults with chronic health care needs and the medical home

Abstract

Background: Currently, there is a call to implement and test the patient-centered medical home in adult populations, particularly among those with chronic conditions. However, the size, composition, and service use of the population who might require this coordinated care model need to be assessed, as does the way they are defined and identified.

Objectives: Using nationally representative data from the 2002 to 2004 Medical Expenditure Panel Survey, we provide a preliminary profile of the population of working-age adults with chronic health care needs (ACHCN), including those with chronic health conditions and disabilities.

Results: ACHCN comprised the majority (52%) of the working-aged population. Relative to persons without chronic health care needs, they had significantly more service use, access problems, and 4 times more health care expenditures. Of the 2 disability groups within the larger population of ACHCN, those reporting need for help or supervision with activities of daily livings (ADLs) or instrumental ADLs (IADLs) had the highest rates/percentages of the following: mean chronic (3.5) and acute (4.4) conditions during the year, service use (all services), and access problems. The ADL/IADL-limited group reported annual medical expenditures totaling 100 billion dollars, more than what was spent on the entire working-age population without chronic health care needs.

Conclusions: These data reveal the drawbacks of selecting the potential population targeted for a medical home on the basis of diagnosis alone. New measurement approaches on the basis of shared need for ongoing health and related services are required to bridge the division between disability and chronic health conditions.

FIGURE 1

Mean number of chronic and acute health conditions among working-age ACHCN and 3 subgroups: Pooled, weighted annual estimates, MEPS 2002–2004. Significance (after controlling the false discovery rate): Acute conditions: All 3 subgroups of ACHCN differ significantly (P < 0.05) from one another and from the contrast group. ACHCN as a whole also have significantly higher mean acute conditions than do the contrast group. Chronic conditions: All 3 subgroups of ACHCN differ significantly from one another.

FIGURE 2

Covariate-controlled marginal percentages reporting delay in or nonreceipt of medical care services and prescription medications: Pooled, weighted annual estimates for all working-age adults and for adults with one or more months uninsured, MEPS 2002–2004. Among all working-age adults, all possible pairwise marginal comparisons of the contrast and 3 ACHCN subgroups differed significantly (P < 0.05) after controlling covariates. This was the case for both the medical services and prescription medication models. Among only adults reporting one or more months uninsured, we again found that all possible pairwise marginal comparisons differed significantly after controlling covariates in both the medical services and prescription medication models.

FIGURE 3

Medical care expenditures from all sources at the population (totals in billons of dollars) and individual (median in dollars) levels, by population group size (percentage of total working-age persons): Pooled, weighted annual estimates, MEPS 2002–2004. Dollar figures reflect inflation adjustment to 2002. We present person level expenditures as medians because the expenditure data are skewed. For reference, the mean total expenditures per person are as follows: Adults without chronic health care needs, $1067.20; ACHCN (all), $4624.33; ACHCN no limitation, $2974.59; ACHCN with limitations not affecting ADLs/IADLs, $6663.22; ACHCN with ADL/IADL limitations, $16,869.49.