Drivers of High-Cost Medical Complexity in a Medicaid Population

David Labby
Bill Wright
Lauren Broffman
Megan Holtorf
Peer-Reviewed Article
March 2020

To improve health outcomes and reduce health care costs and utilization for people with complex needs, it is important to understand the underlying social and behavioral issues that may be driving medical complexity and high costs. This study assessed the relationship between early and later-life social adversity and the risk of high medical costs and/or acute care utilization among a sample of Oregon Medicaid enrollees.

Individuals with medically complex needs experienced higher rates of adverse life experiences than healthy people. Over half of those at risk for high health care costs had more than four adverse childhood experiences (ACEs), compared to around 30 percent in the low-cost group. Those at risk for high health care costs were also twice as likely to have experienced substance abuse, housing instability, and incarceration. Individuals with the highest rates of utilization in the previous year were also far more likely to have experienced these adversities.

The study results suggest four critical upstream opportunities for complex care programs seeking to mitigate high-impact social drivers of poor outcomes and reduce the potential for poor health and high utilization: (1) transforming the addiction treatment system; (2) engaging with housing initiatives; (3) promoting workflow integration across criminal justice and health care sectors and improving diversion to treatment and community reintegration; and (4) addressing life trauma, including early life interventions and incorporating trauma-informed practices.

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