Drivers of High-Cost Medical Complexity in a Medicaid Population.

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Medical care




BACKGROUND: 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, 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.


Population Health