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The American Journal of Managed Care September 2018
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Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
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Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study

Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
In a longitudinal study, the authors find that food insecurity is associated with greater emergency department visits, inpatient admissions, and length of stay.
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Reducing utilization of high-cost healthcare services is a common population health goal. Food insecurity—limited access to nutritious food owing to cost—is associated with chronic disease, but its relationship with healthcare utilization is understudied. We tested whether food insecurity is associated with increased emergency department (ED) visits, hospitalizations, and related costs.

Study Design: Retrospective analysis of a nationally representative cohort.

Methods: Adults (≥18 years) completed a food insecurity assessment (using 10 items derived from the US Department of Agriculture Household Food Security Module) in the 2011 National Health Interview Survey and were followed in the 2012-2013 Medical Expenditures Panel Survey. Outcome measures were ED visits, hospitalizations, days hospitalized, and whether participants were in the top 10%, 5%, or 2% of total healthcare expenditures.

Results: Of 11,781 participants, 2056 (weighted percentage, 13.2%) were in food-insecure households. Food insecurity was associated with significantly more ED visits (incidence rate ratio [IRR], 1.47; 95% CI, 1.12-1.93), hospitalizations (IRR, 1.47; 95% CI, 1.14-1.88), and days hospitalized (IRR, 1.54; 95% CI, 1.06-2.24) after adjustment for demographics, education, income, health insurance, region, and rural residence. Food insecurity was also associated with increased odds of being in the top 10% (odds ratio [OR], 1.73; 95% CI, 1.31-2.27), 5% (OR, 2.53; 95% CI, 1.51-3.37), or 2% (OR, 1.95; 95% CI, 1.09-3.49) of healthcare expenditures.

Conclusions: Food insecurity is associated with higher healthcare use and costs, even accounting for other socioeconomic factors. Whether food insecurity interventions improve healthcare utilization and cost should be tested.

Am J Manag Care. 2018;24(9):399-404
Takeaway Points
  • Food insecurity is an important risk factor for use of emergency department and inpatient healthcare services.
  • Those with the highest healthcare costs are often food-insecure.
  • Improving healthcare use for those with the highest costs may require addressing needs such as food insecurity along with medical needs.
A disproportionately large share of healthcare costs is generated in the course of care for a small proportion of patients, which is often due to emergency department (ED) visits, inpatient hospitalizations, or long lengths of hospital stay.1,2 The desire to improve use of these services has prompted investigations into risk factors for high use and costs. Programs targeting patients with particularly high total healthcare costs3 (eg, those in the top 10%, 5%, or 1%) typically focus on clinical conditions or factors internal to the healthcare system, such as care coordination.2 Because the impact of these programs can be modest,2 there has recently been increased interest in addressing modifiable social determinants of health with the intention of reducing healthcare utilization and cost (eg, through the Accountable Health Communities model proposed by CMS).4

One particular area of focus is food insecurity, defined as lacking “access to enough food for an active, healthy life for all household members.”5 Food insecurity affects 12.7% of American households as of 20155 and has been associated with increased prevalence of illness, as well as worsened chronic disease management.6-11 It is hypothesized that food insecurity increases healthcare utilization and cost by making it more difficult to follow a healthy diet (exacerbating diet-dependent conditions, such as type 2 diabetes and congestive heart failure); forcing competing demands between food and other necessities, such as medications or transportation; and reducing the cognitive bandwidth necessary to manage chronic illness.9,12 Prior studies in both Canadian13 and American14-16 contexts have found that food insecurity is associated with higher average healthcare costs. However, several of these studies had limitations, including cross-sectional13 and ecological designs,15,16 and none focused on the most relevant group for population health management—those with the highest healthcare use. For population health management, the extremes of the distribution, rather than the mean, may be most relevant.

To address these issues, we tested the hypothesis that food insecurity is associated with higher utilization of ED services, inpatient hospital admissions, and length of stay and an increased risk of being in top percentiles (10%, 5%, and 2%) of total healthcare expenditures, accounting for socioeconomic covariates.


Data Source and Study Sample

Data for this study were obtained from the 2011 National Health Interview Survey (NHIS)17 and the 2012-2013 Medical Expenditure Panel Survey (MEPS). The 2012-2013 panel of MEPS is drawn from respondents to the 2011 NHIS to be nationally representative, and the responses were linked by anonymized identification number.18 We included all adults (≥18 years at time of NHIS completion) with information on food security status (nonresponse rate for food insecurity items, <1%)19 in our analysis. Interviews were conducted by trained interviewers in English or Spanish.17,18

The Human Research Committee at Partners Healthcare exempted this study from human subjects review, as it made use of deidentified data.

Food Insecurity

Food insecurity was assessed at the household level with a 30-day lookback period in the NHIS using a 10-item food insecurity instrument derived from the US Department of Agriculture Household Food Security Module.20 An example item asked whether the respondent and their household often, sometimes, or never worried about whether “food would run out before [they] had money to get more.” An affirmative response to 3 or more items indicated food insecurity, in accord with standard scoring practices for this instrument.20 Owing to sample size limitations, we did not further subdivide the food-insecure category into low versus very low food security. These data came from the 2011 NHIS.

Healthcare Utilization and Expenditures

Information on healthcare expenditures and use that occurred in 2012 and 2013 was taken from MEPS. Because they are often the focus of programs to reduce healthcare utilization,2 we evaluated the number of ED visits not resulting in a hospital admission, the number of inpatient hospital admissions, and the number of days spent as a hospital inpatient. To provide context, we also examined the medical conditions associated with use of these services and outpatient service use. Because a disproportionate share of total healthcare costs is attributable to a small number of people with the highest costs, it is important to understand other parts of the distribution of healthcare expenditures besides the mean. Therefore, we examined those in 3 commonly used thresholds: those in the top 10% of expenditures, those in the top 5%, and those in the top 2%.1 Using the top 2% rather than the top 1% gives more stable estimates owing to the larger sample sizes. For consistency, we used the Consumer Price Index to convert all expenditures to 2015 dollars.

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