Predicting high-cost, commercially-insured people with diabetes in Texas: Characteristics, medical utilization patterns, and urban-rural comparisons.

Abstract

Background: Type 2 diabetes mellitus (T2DM) is a prevalent chronic disease in the United States and healthcare resources used to manage the disease are disproportionately consumed by a small subset of users. Consequently, there is a potential to reduce the healthcare costs and to improve the health outcomes through the early detection and consistent management of high-cost users.

Objective: The objectives of this study were to characterize the pattern of medical utilization and cost of commercially-insured people with type 2 diabetes (T2DM) in Texas and to identify predictors of high-cost users.

Methods: Using claims data from a large commercial insurance plan spanning the period from 2016 to 2019, the total medical costs of a randomly selected 12-month period were analyzed for eligible commercially-insured people with T2DM, and the patients were categorized into the top 20% of high-cost users and the bottom 80% of lower-cost users. Descriptive analyses were conducted to describe the baseline characteristics of the people with T2DM, the patterns of healthcare utilization, and the costs of the two types of users. Multivariate logistic regression models were estimated to identify the predictors of being a high-cost T2DM user.

Results: The top 20% of high-cost users accounted for 83% of the total medical cost, with an average cost of $41,370 as compared to only $2064 for the bottom 80% of lower-cost users. Several chronic conditions were identified to be strong predictors of being a high-cost patient. Rural high-cost users had, on average, fewer specialist visits but more inpatient stays compared to the urban high-cost users.

Conclusion: Healthcare utilization and expenditures among commercially insured individuals with T2DM followed the 80-20 rule. High-cost users were strongly associated with worse health status. Residential rurality was not associated with high-cost use, though the patterns of resource utilization differed between urban and rural high-cost users.