Nancy Garrett1, Jeremy A Bikah Bi Nguema Engoang2, Stephen Rubin2, Katherine Diaz Vickery3, Tyler N A Winkelman4. 1. Analytics Center of Excellence, Hennepin Healthcare, Minneapolis, MN, USA; Aetna, Hartford, CT, USA. 2. Analytics Center of Excellence, Hennepin Healthcare, Minneapolis, MN, USA. 3. Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Health, Homelessness, And Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA. 4. Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Health, Homelessness, And Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA. Electronic address: tyler.winkelman@hcmed.org.
Abstract
BACKGROUND: Costs incurred by health systems when caring for populations with social or behavioral complexity are poorly understood. We compared the frequency and costs of unreimbursed care among individuals with complexity factors (homelessness, a history of county jail incarceration, and/or substance use disorder or mental illness [SUD/MI]). METHODS: We conducted a cross-sectional analysis using electronic health record data for adults aged 18 and older between January 1, 2016 and December 31, 2017 from a Midwestern safety-net health system. Zero-inflated negative binomial regression models were used to assess risk-adjusted associations between complexity factors and care coordination encounters, missed appointments, and excess inpatient days. RESULTS: Our sample included 154,719 unique patients; 6.8% were identified as homeless, 7.8% had a history of county jail incarceration, and 20.6% had SUD/MI. Individuals with complexity factors were more likely to be African-American, Native American, or covered by Medicaid. In adjusted models, homelessness and SUD/MI were significantly associated with care coordination encounters (RR 1.8 [95% CI,1.7-2.0]; RR 1.9 [95% CI,1.8-2.0]), missed appointments (RR 1.5 [95% CI,1.4-1.6]; RR 1.7 [95% CI,1.7-1.8]), and excess inpatient days (RR 1.5 [95% CI,1.3-1.8]; RR 2.8 [95% CI,2.5-3.1]). County jail incarceration was associated with a significant increase in missed appointments. In 2017, SUD/MI accounted for 81.8% ($7,773,000/$9,502,000) of excess costs among those with social or behavioral complexity. CONCLUSIONS: Social and behavioral complexity are independently associated with high levels of unreimbursed health system resource use. IMPLICATIONS: Future payment models should account for the health system resources required to care for populations with complex social and behavioral needs. LEVEL OF EVIDENCE: IV.
BACKGROUND: Costs incurred by health systems when caring for populations with social or behavioral complexity are poorly understood. We compared the frequency and costs of unreimbursed care among individuals with complexity factors (homelessness, a history of county jail incarceration, and/or substance use disorder or mental illness [SUD/MI]). METHODS: We conducted a cross-sectional analysis using electronic health record data for adults aged 18 and older between January 1, 2016 and December 31, 2017 from a Midwestern safety-net health system. Zero-inflated negative binomial regression models were used to assess risk-adjusted associations between complexity factors and care coordination encounters, missed appointments, and excess inpatient days. RESULTS: Our sample included 154,719 unique patients; 6.8% were identified as homeless, 7.8% had a history of county jail incarceration, and 20.6% had SUD/MI. Individuals with complexity factors were more likely to be African-American, Native American, or covered by Medicaid. In adjusted models, homelessness and SUD/MI were significantly associated with care coordination encounters (RR 1.8 [95% CI,1.7-2.0]; RR 1.9 [95% CI,1.8-2.0]), missed appointments (RR 1.5 [95% CI,1.4-1.6]; RR 1.7 [95% CI,1.7-1.8]), and excess inpatient days (RR 1.5 [95% CI,1.3-1.8]; RR 2.8 [95% CI,2.5-3.1]). County jail incarceration was associated with a significant increase in missed appointments. In 2017, SUD/MI accounted for 81.8% ($7,773,000/$9,502,000) of excess costs among those with social or behavioral complexity. CONCLUSIONS: Social and behavioral complexity are independently associated with high levels of unreimbursed health system resource use. IMPLICATIONS: Future payment models should account for the health system resources required to care for populations with complex social and behavioral needs. LEVEL OF EVIDENCE: IV.
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