William B Weeks1, James N Weinstein2. 1. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; The Geisel School of Medicine, Hanover, NH. Electronic address: wbw@dartmouth.edu. 2. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; The Geisel School of Medicine, Hanover, NH; Dartmouth-Hitchcock Health, Lebanon, NH.
Abstract
PURPOSE: To determine whether several measures of health care expenditures, access, and outcomes for the 25 recently identified "least healthy cities in America" differed from those in the rest of America. METHODS: For 2004 and 2013, we obtained publicly available price-, age-, sex-, and race-adjusted hospital service area per-capita Medicare expenditures; age-, sex-, and race-adjusted Medicare mortality rates; and 2 indicators of primary care access: the proportion of enrollees having at least one ambulatory visit to a primary care clinician and the per-capita discharge rate for ambulatory care sensitive conditions. Using population weighting, we used Student t test for expenditure data and the chi-squared test for access and outcomes data to compare results of the 25 least healthy cities in aggregate to the rest of America. RESULTS: In both years examined, the 25 least healthy cities had substantially (about $500 per capita per year) and statistically significantly higher total per-capita Medicare Part A and Part B expenditures than the rest of America: about 4/5 of this difference was due to higher hospital and skilled nursing facility expenditures; physician expenditures were modestly lower in the 25 least healthy cities. While a greater proportion of Medicare beneficiaries in the least healthy cities had a primary care clinician both years, mortality and ambulatory care sensitive condition admission rates were substantially higher in the least healthy cities. CONCLUSIONS: Policymakers and health system executives should work together to determine the best asset allocation across determinants of health that maximizes value creation from a community health perspective.
PURPOSE: To determine whether several measures of health care expenditures, access, and outcomes for the 25 recently identified "least healthy cities in America" differed from those in the rest of America. METHODS: For 2004 and 2013, we obtained publicly available price-, age-, sex-, and race-adjusted hospital service area per-capita Medicare expenditures; age-, sex-, and race-adjusted Medicare mortality rates; and 2 indicators of primary care access: the proportion of enrollees having at least one ambulatory visit to a primary care clinician and the per-capita discharge rate for ambulatory care sensitive conditions. Using population weighting, we used Student t test for expenditure data and the chi-squared test for access and outcomes data to compare results of the 25 least healthy cities in aggregate to the rest of America. RESULTS: In both years examined, the 25 least healthy cities had substantially (about $500 per capita per year) and statistically significantly higher total per-capita Medicare Part A and Part B expenditures than the rest of America: about 4/5 of this difference was due to higher hospital and skilled nursing facility expenditures; physician expenditures were modestly lower in the 25 least healthy cities. While a greater proportion of Medicare beneficiaries in the least healthy cities had a primary care clinician both years, mortality and ambulatory care sensitive condition admission rates were substantially higher in the least healthy cities. CONCLUSIONS: Policymakers and health system executives should work together to determine the best asset allocation across determinants of health that maximizes value creation from a community health perspective.