Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending | Health Disparities | JAMA Network Open | JAMA Network
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    Original Investigation
    Health Policy
    June 10, 2021

    Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending

    Author Affiliations
    • 1Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
    JAMA Netw Open. 2021;4(6):e2113212. doi:10.1001/jamanetworkopen.2021.13212
    Key Points

    Question  How much variation in Medicare per beneficiary spending across counties was associated with social determinants of health (SDoH)?

    Findings  In this cross-sectional study, SDoH were associated with 37.7% of variation in price-adjusted Medicare per beneficiary spending between counties in the highest and lowest quintiles of spending in 2017, including both direct contributions and indirect contributions through other factors. SDoH’s direct contribution accounted for 5.8% of the variation after controlling for patient demographic characteristics, clinical risk, and supply of health care resources.

    Meaning  These findings suggest that addressing SDoH is important for reducing geographic spending variation and improving the value of health care.

    Abstract

    Importance  Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation.

    Objective  To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending.

    Design, Setting, and Participants  This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH.

    Main Outcomes and Measures  2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context.

    Results  Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P < .001). The total contribution (including through both direct and indirect pathways) of SDoH was 37.7% ($1428 of $3785) of this variation, compared with 59.8% ($2265 of $3785) by patient clinical risk, 14.5% ($549 of $3785) by supply of health care resources, and 19.8% ($751 of $3785) by patient demographic characteristics. When all factors were included within the same model, the direct contribution of SDoH was associated with 5.8% of the variation, compared with 4.6% by supply, 4.7% by patient demographic characteristics, and 62.0% by patient clinical risk.

    Conclusions and Relevance  These findings suggest social determinants of health are associated with considerable proportions of geographic variation in Medicare spending. Policies addressing SDoH for disadvantaged patients in certain regions have the potential to contain health care spending and improve the value of health care; patient SDoH may need to be accounted for in publicly reported physician performance, and in value-based purchasing incentive programs for health care professionals.

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