Associations Between Different Self-reported Social Risks and Neighborhood-level Resources in Medicaid Patients

Abstract

Background: Adverse social conditions are a key contributor to health disparities. Improved understanding of how social risk factors interact with each other and with neighborhood characteristics may inform efforts to reduce health disparities.Data: A questionnaire of 29,281 patients was collected through the enrollment of Medicaid beneficiaries in a large Northern California integrated health care delivery system between May 2016 and February 2020.Exposures: Living in the least resourced quartile of neighborhoods as measured by a census-tract level Neighborhood Deprivation Index score.Main Outcomes: Five self-reported social risk factors: financial need, food insecurity, housing barriers, transportation barriers, and functional limitations.Results: Nearly half (42.0%) of patients reported at least 1 social risk factor; 22.4% reported 2 or more. Mean correlation coefficient between social risk factors was ρ = 0.30. Multivariable logistic models controlling for age, race/ethnicity, sex, count of chronic conditions, and insurance source estimated that living in the least resourced neighborhoods was associated with greater odds of food insecurity (adjusted odds ratio = 1.07, 95% confidence interval: 1.00-1.13) and transportation barriers (adjusted odds ratio = 1.20, 95% confidence interval: 1.11-1.30), but not financial stress, housing barriers, or functional limitations.Conclusions and Relevance: We found that among 5 commonly associated social risk factors, Medicaid patients in a large Northern California health system typically reported only a single factor and that these factors did not correlate strongly with each other. We found only modestly greater social risk reported by patients in the least resourced neighborhoods. These results suggest that individuallevel interventions should be targeted to specific needs whereas community-level interventions may be similarly important across diverse neighborhoods.

Association Between Community-Level Social Risk and Spending Among Medicare Beneficiaries

“…This suggests that incorporating community-level social risk factors, even at the granular census block group level, may not meaningfully improve the calibration of risk adjustment models among Medicare beneficiaries. Whereas we believe our study is the first to evaluate this association in a Medicare Advantage population and using the ADI, prior research has found measures of community-level social risk to be poor proxies for individual social needs …”

“…Whereas we believe our study is the first to evaluate this association in a Medicare Advantage population and using the ADI, prior research has found measures of community-level social risk to be poor proxies for individual social needs. 22,23 Although relatively weak in magnitude, there was a significant association between ADI and health care spending. Considered alone, increases in ADI (ie, more disadvantage) were associated with increased spending.…”

Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review

“…9 Seven articles (39%) were published between 2013 and 2015, [8][9][10][11][12]16,20 while the remaining articles (61%) were published between 2016 and 2018. 4,[13][14][15][17][18][19][21][22][23][24][25][26][27][28][29][30][31]33 Sixteen articles (89%) specified the timeline in which GIS data were captured. 8,[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Of these 16 articles, 14 (88%) examined data collected within the past 10 years before publication 8,10-12,14,16-24 and 2 (13%) examined data from the past 11 to 20 years.…”

Accounting for Person- vs Neighborhood-Level Social Risk in Quality Measurement

“…To date, studies have raised concern that community-level social risk may be an inaccurate proxy for individual social needs. 6,7 Consequently, the strength of their associations with clinical outcomes tends to be lesser than for the individual measures, a finding noted by Lipska and colleagues. 3 Furthermore, given that individuals living in areas with poor health care access may have high levels of unmet clinical need, and therefore suboptimal utilization patterns at baseline, there is concern that use of community-level variables in risk adjustment for payment determinations may reinforce underlying issues of structural racism and discrimination.…”

“…The key disadvantage of area-level measures, however, is that they are prone to the very serious issue of ecological fallacy, whereby one makes erroneous assumptions about individuals based on aggregated data. To date, studies have raised concern that community-level social risk may be an inaccurate proxy for individual social needs . Consequently, the strength of their associations with clinical outcomes tends to be lesser than for the individual measures, a finding noted by Lipska and colleagues .…”