Do not skip the appendices. That is what I learned the other day while researching the drivers of high-cost health care. Somehow, I stumbled into “Appendix E: Epidemiology of Serious Illness and High Utilization of Health Care” from Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.1  This fascinating Appendix was written by Drs. Melissa Aldridge and Amy Kelley, and contains an extensive analysis of the drivers of high-cost health care in the United States.

The most interesting thread in this publication was the influence of functional limitations on health care costs. Many common statistics point to chronic conditions as a key driver of health care spending, but an analysis by The Lewin Group (2010) that was reported to the Department of Health and Human Services concluded that the combination of chronic conditions and functional limitations was a better predictor of high medical costs than the number of chronic conditions alone.2  In fact, although individuals with both chronic conditions and functional limitations combined make up only 14% of the population, their costs add up to 56% ($909 billion) in health care spending, or a staggering 72% of the top 5% of health care spenders.

Yet, these high spenders are not the same ones who break the bank every year. Of those ranking in the top 5% one year, a full 62% do not return to the high spending category the following year.3 Therefore, it appears that these individuals experienced acute conditions that were successfully treated or eventually resolved. Given these facts, Drs. Aldridge and Kelley suggested that tracking functional limitations would aid medical cost and utilization research to flag which population members are predicted to be high spenders.

In my opinion, an inability to work is probably the best available marker we have that reflects functional limitations in adults. After all, in many cases a return to functional activities in the home and community mirrors the ability of a person to perform work activities. Much of the research we conduct at MDGuidelines involves work disability, and the findings in Appendix E support our belief that both patients and payers benefit when individuals regain functional health through the appropriate care at the appropriate time. To help reduce the disproportionate share of health care spending due to functional limitations, occupational absences should be considered as useful reflection on population health.


  1. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academy of Sciences; 2015.
  2. Aleckxih L, Shen S, Chan I, Taylor D, Drabek J. Individuals Living in the Community with Chronic Conditions and Functional Limitations: A Closer Look. Lewin Gr. 2010.
  3. National Institute for Health Care Management Foundation. The Concentration of Health Care Spending. Data Br. 2012:1-12.
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