Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population
- 1 October 2022
- journal article
- research article
- Published by Mary Ann Liebert Inc in Population Health Management
- Vol. 25 (5), 658-668
- https://doi.org/10.1089/pop.2022.0069
Abstract
Patients enrolled in Medicaid have significantly higher social needs (SNs) than others. Using claims and electronic health records (EHRs) data, managed care organizations (MCOs) could systemically identify high-risk patients with SNs and develop population health management interventions. Impact of SNs on models predicting health care utilization and costs was assessed. This retrospective study included claims and EHRs data on 39,267 patients younger than age 65 years who were continuously enrolled during 2018–2019 in a Medicaid-managed care plan. SN marker was developed suggesting presence of International Classification of Diseases, 10th revision codes in any of the 5 SN domains. Impact of SN marker was compared across demographic and 2 diagnosis-based (ie, Charlson and Adjusted Clinical Groups risk score) prediction models of emergency department (ED) visit and hospitalizations, and total, medical, and pharmacy costs. After combining data sources, prevalence of documented SN marker increased from 11% and 13% to 18% of the study population across claims, EHRs, and both combined, respectively. SN marker improved predictions of demographic models for all utilization and total costs outcomes (area under the curve [AUC] of ED model increased from 0.57 to 0.61 and R2 of total cost model increased from 10.9 to 12.2). In both diagnosis-based models, adding SN marker marginally improved outcomes prediction (AUC of ED model increased from 0.65 to 0.66). This study demonstrated feasibility of using claims and EHRs data to systematically capture SNs and incorporate in prediction models that could enable MCOs and policy makers to adjust and develop effective population health interventions.Keywords
This publication has 32 references indexed in Scilit:
- Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction programHealth Services Research, 2019
- Documenting social determinants of health-related clinical activities using standardized medical vocabulariesJAMIA Open, 2018
- Social Determinants of Health in Managed Care Payment FormulasJAMA Internal Medicine, 2017
- Understanding Medicaid Managed Care Investments in Members' Social Determinants of HealthPopulation Health Management, 2017
- Risk Prediction for Adverse Pregnancy Outcomes in a Medicaid PopulationJournal of Women's Health, 2015
- Impact of alternative approaches to assess outlying and influential observations on health care costsSpringerPlus, 2013
- Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory CareHealth Affairs, 2013
- The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patientsJournal of Clinical Epidemiology, 2008
- Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative DataMedical Care, 2005
- Bringing context back into epidemiology: variables and fallacies in multilevel analysis.American Journal of Public Health, 1998