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More high-cost health care users live in lower socioeconomic status neighborhoods, study shows

Adults 65 years and older in disadvantaged neighborhoods were more likely to use high-cost care while the impact on children and young adults was limited
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A growing focus in health care systems is delivering high quality care while reducing costs. However, costs are not divided equally among patients. A relatively small proportion of patients who need extensive care represent a large fraction of overall health care expenditures. Research has found that factors like income and education may affect health and quality of life. These social determinants of health (SDOH) could play a notable role in health care system use, but it is unclear how SDOH and health care use varies among different age groups.

A new study published in the American Journal of Managed Care explores how neighborhood-level SDOH factors and age could be associated with high-cost health care use. In the study, Elena Andreyeva, PhD, assistant professor in the Department of Health Policy and Management at the Texas A&M University School of Public Health, developed a model to determine whether adding neighborhood-level characteristics to existing tools that use demographic and clinical information can lead to more accurate predictions and assess differences in SDOH and high-cost use between age groups. Being better able to use various SDOH factors to predict high-cost health care use could enable better care and guide interventions that improve health outcomes while reducing costs.

The researchers used data from a large national health insurer to explore these issues. They randomly selected just over 3 million insurance subscribers who were younger than 89 years old, had a full year of enrollment in 2017 and at least 30 days of enrollment in 2018. Their analysis looked at the top 10 percent of health care expenditures for 2018. They grouped members by state to account for variations in care costs across the country and excluded care for cancer and transplants as those expensive treatments could skew their results. The researchers then used an SDOH index that included factors like unemployment rate, median household income and education level and individual characteristics like age, gender and health care system use and costs.

Their analysis found that, overall, more high-cost health care users lived in lower socioeconomic status neighborhoods. Similarly, neighborhoods with the highest socioeconomic status had far fewer high-cost users. However, when considering age, the researchers found that children and young adults in higher socioeconomic status neighborhoods were more likely to be high-cost users than children in more disadvantaged neighborhoods. The inverse also appeared in the analysis, with adults older than 65 in poorer areas being more likely to be high-cost users.

The researchers say one possible reason for the higher prevalence of high-cost children and young adults in neighborhoods with higher socioeconomic status could be better access to health insurance and quality care. In contrast, they say, the greater presence of high-cost older adults in lower income areas could be due to poorer health among that population. This indicates a possible difference in what drives relationships between high-cost user status and socioeconomic factors in different age groups.

The findings of this study reinforce the possible correlation between socioeconomic status, housing quality and other factors and the need for costly health care services. Further understanding of the effects of SDOH could inform badly needed policies that consider different factors at play in health care costs.

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