According to a study published in JAMA Network Open, the overall well-being of a geographically defined population — measured in part by the physical, mental, and social health of a county — was inversely associated with the amount Medicare spent on its fee-for-service beneficiaries.

The authors of this cross-sectional survey-based study sought to assess whether the overall health of a population was associated with healthcare spending for people aged 65 years and older. A holistic assessment of population well-being involved different relevant domains, including physical, mental, and social health, measured by the Gallup-Sharecare Well-Being Index. These data were linked to mean spending per Medicare fee-for-service beneficiary and county characteristics data for all counties in the United States. The authors assessed independent associations of spending and population well-being using weighted regression models. Data was adjusted for 4 prevalent health conditions (stroke, hip fracture, colorectal cancer, and acute myocardial infarction) and regional penetration of Medicare Advantage.

The authors assessed 2998 US counties using county-level mean values to describe the overall demographic characteristics of the participants, who were 50.8% female, 74.9% white, 12.1% black, 4.0% Asian, and 13.7% Hispanic. The median age of was 38.2 years. Medicare spending per beneficiary ranged from $5374 to $15,967 for individual counties, with counties in the highest quintile of well-being spending significantly less than counties in the lowest quintile of well-being. This inverse association persisted even after adjusting the models for key population characteristics, including median household income, percentage of urban residents, and healthcare system capacity.

In the fully adjusted model, Medicare spent a mean of $992 less per beneficiary in the highest well-being counties than the lowest well-being counties. The authors assessed independent associations with each domain of well-being, and the greatest difference in spending was observed in the context of access to basic needs: Medicare spent a mean of $1233 less per beneficiary in counties with the greatest access to basic needs vs those with limited access.

Limitations of the study included its cross-sectional nature, in which causation cannot be inferred, and the potential for endogeneity to influence the results, particularly in the case of physical health as a domain of overall well-being. Another limitation was that the data used for this study was drawn from 2010 Well-Being Index survey and 2010 Medicare spending data. Finally, healthcare spending data was limited to data of the Medicare fee-for-service population; the association between well-being and other insured or uninsured populations was not assessed.

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This inverse association was consistent across all domains of population well-being and was most strongly linked to the access of basic needs, followed by emotional health, healthy behaviors, and physical health. “Identifying this association…at the population level may help to lay the foundation for further study to first illuminate the mechanisms underlying the association and to second study interventions aimed at creating greater well-being and lower health care spending at the population level,” the researchers concluded.


Riley C, Roy B, Herrin J, etc. Association of the overall ell-being of a population with health care spending for people 65 years of age or older [published online September 14, 2018]. JAMA Netw Open. doi:10.1001/jamanetworkopen.2018.2136