Drivers of High-cost Medical Complexity in a Medicaid Population

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.