Designing health care for the most common chronic condition--multimorbidity.

THE MOST COMMON CHRONIC CONDITION EXPERIenced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions. In patients with coronary disease, for example, it is the sole condition in only 17% of cases. Almost 3 in 4 individuals aged 65 years and older have multiple chronic conditions, as do 1 in 4 adults younger than 65 years who receive health care. Adults with multiple chronic conditions are the major users of health care services at all adult ages, and account for more than two-thirds of health care spending. Despite the predominance of multiple chronic conditions, however, reimbursement remains linked to discrete International Classification of Diseases diagnostic codes, none of which are for multimorbidity or multiple chronic conditions. Specialists are responsible for a single disease among the patient’s many. Quality measurement largely ignores the unintended consequences of applying the multiple interventions necessary to adhere to every applicable measure. Uncertain benefit and potential harm of numerous simultaneous treatments, worsening of a single disease by treatment of a coexisting one, and treatment burden arising from following several disease guidelines are the welldocumented challenges of clinical decision making for patients with multiple chronic conditions. To ensure safe and effective care for adults with multiple chronic conditions, particularly the millions of baby boomers entering their years of declining health and increasing health service use, health care must shift its current focus on managing innumerable individual diseases. To align with the clinical reality of multimorbidity, care should evolve from a disease orientation to a patient goal orientation, focused on maximizing the health goals of individual patients with unique sets of risks, conditions, and priorities. Patient goal– oriented health care involves ascertaining a patient’s health outcome priorities and goals, identifying the diseases and other modifiable factors impeding these goals, calculating and communicating the likely effect of alternative treatments on these goals, and guiding shared decision making informed by this information. Changes Needed in Quality Measurement, Health Care Delivery, and Payment