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Drivers of High-cost Medical Complexity in a Medicaid Population

Authors
  • Labby, David1
  • Wright, Bill2
  • Broffman, Lauren3
  • Holtorf, Megan2
  • 1 Health Share of Oregon
  • 2 Center for Outcomes Research and Education, Portland, OR
  • 3 Ro, New York, NY
Type
Published Article
Journal
Medical Care
Publisher
Lippincott Williams & Wilkins
Publication Date
Dec 23, 2019
Volume
58
Issue
3
Pages
208–215
Identifiers
DOI: 10.1097/MLR.0000000000001261
PMID: 31876646
PMCID: PMC7017939
Source
PubMed Central
Keywords
License
Green

Abstract

Efforts to improve outcomes for the 10% of patients using two thirds of health care expenditures increasingly include addressing social determinants. Empiric evidence is needed to identify the highest impact nonmedical drivers of medical complexity and cost. Objectives: This study examines whether complex, highest cost patients have different patterns of critical life adversity than those with better health and lower utilization. Research Design: Using a validated algorithm we constructed a complexity/cost risk patient profile. We developed and fielded a life experience survey (Supplemental Digital Content 1, http://links.lww.com/MLR/B920 ) to a representative sample, then examined how the prevalence of specific adversities varied between complex, high-cost individuals, and others. Subjects: Surveys were sent to 9176 adult Medicaid members in Portland, Oregon. Measures: Our primary variable was high medical complexity health cost risk; an alternative specification combined health cost risk and actual utilization/cost. Our survey instrument measured exposure to early and later-life adversities. Results: Compared with healthy individuals in our population, medically complex individuals had significantly higher rates of adversity. The greatest risk of medical complexity and cost was associated with substance use [odds ratio (OR), 4.1], homelessness (OR, 3.0), childhood maltreatment (OR, 2.8), and incarceration (OR 2.4). Those with the highest prior year acute care utilization and cost had the highest rates of these same factors: substance use (62.5%), homelessness (61.7%), childhood maltreatment (55.5%), and incarceration (52.1%). Conclusion: Clinical and policy strategies that mitigate high-impact social drivers of poor outcomes are likely critical for improving both health and costs for complex, high-needs patients.

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