Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York.
JAMA Netw Open. 2021 Jun 1;4(6):e2113212. doi: 10.1001/jamanetworkopen.2021.13212.
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.
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.
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.
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.
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.
尽管美国医疗保险每位受益人的支出在地理上存在很大差异，但人们对健康的社会决定因素（SDoH）与这种差异的关联程度知之甚少。
确定 SDoH 与县级价格调整后每位医疗保险受益人的支出之间的关系。
设计、地点和参与者：这项横断面研究使用了来自多个来源的 2017 年医疗保险按服务收费（FFS）支出、患者人口统计学特征（如年龄和性别）和临床风险评分、医疗资源供应（如医院床位数量）以及 SDoH 措施（如中位数收入和失业率）的县级数据。使用多变量回归估计支出在五分位数之间的变化与 SDoH 的关联。
2017 年县级价格调整后的每位医疗保险 A 部分和 B 部分受益人的支出。SDoH 措施包括社会经济地位、种族/民族、社会关系以及居住和社区环境。
在 3038 个有 33495776 名医疗保险 FFS 受益人的县中（18352336[54.8%]名女性；平均[标准差]年龄为 72[1.5]岁），支出最高五分位数的县的医疗保险价格调整后每位受益人的支出比支出最低五分位数的县高 3785 美元（95%CI，3706-3862 美元），即高 49%（每位受益人的平均支出[标准差]，11464[735]美元对 7679[522]美元；P<.001）。SDoH 的总贡献（包括直接和间接途径）为 37.7%（3785 美元中的 1428 美元），而患者临床风险为 59.8%（3785 美元中的 2265 美元），医疗保健资源供应为 14.5%（3785 美元中的 549 美元），患者人口统计学特征为 19.8%（3785 美元中的 751 美元）。当所有因素都包含在同一个模型中时，SDoH 的直接贡献与 5.8%的变异有关，而供应因素为 4.6%，患者人口统计学特征为 4.7%，患者临床风险为 62.0%。
这些发现表明，健康的社会决定因素与医疗保险支出的相当大比例的地理差异有关。针对某些地区弱势患者的社会决定因素的政策有可能控制医疗保健支出并提高医疗保健的价值；患者的 SDoH 可能需要在公开报告的医生绩效中考虑，并在医疗保健专业人员的基于价值的购买激励计划中考虑。
