Addressing multimorbidity is critical to an effective population health strategy

November 17th, 2021
Population Health Management & Improvement  |  
Risk Stratification & Population Segmentation
Addressing multimorbidity is critical to an effective population health strategy

In the population health analytics world, we know that patients with multiple health conditions (or “multimorbidity”) have unique health needs that present numerous challenges to health systems and providers. Multimorbid patients have more office visits and are more often hospitalized, and they require individualized care to manage their multiple chronic illnesses.  That’s why no population health strategy is complete without a plan to address these complex “multimorbid” patients.

Case in Point

To illustrate, we selected a particular population (in this case, people with diabetes) and grouped them into low, moderate, high or very high multimorbidity as determined by the ACG System’s Resource Utilization Bands, or RUBs.

Over the course of a year, diabetic patients with the highest level of multimorbidity have six times more specialist visits, three times more PCP visits and four times more visits related to conditions other than diabetes compared to low-morbidity diabetic patients. While this highly multimorbid patient group comprises just 13% of all diabetic patients, they account for 36% of all emergency department visits.

Diabetic patients with very high multimorbidity have a 43% hospitalization rate compared to less than 2% for low-morbidity patients with diabetes. In fact, multimorbid diabetic patients are five times more likely to be readmitted to a hospital within a year compared to diabetic patients with low morbidity. All these statistics point to one thing: identifying and managing multimorbid patient groups is essential to control rising costs and utilization.


While the above statistics are specific to diabetes, the patterns of utilization are consistent with highly complex patients regardless of the specific condition(s). And high utilization generally equals higher cost. To effectively manage the health of your population, you need to first understand the multimorbidity—a much better predictor of resource utilization than a single disease or health care event.

Learn more about how the ACG System identifies those with predicted high health care need based on multimorbidity by downloading this infographic.




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