Drivers of Variation in Health Care Spending Across US Counties
Authors: Dieleman Joseph L. , Weil Maxwell , Beauchamp Meera , Bisignano Catherine , Crosby Sawyer W. , DeJarnatt Drew , Lescinsky Haley , Mokdad Ali H. , Ostroff Samuel , Paul Hilary , Pollock Ian , Sahu Maitreyi , Scott John W. , Taylor Kayla V. , Thomson Azalea , Weaver Marcia R. , Wilner Lauren B. , Murray Christopher J. L. 
Published: February 2025

Importance

Understanding the drivers of health care spending across US counties is important for developing policies and assessing the allocation of health care services.

Objective

To estimate the amount of cross-county health care spending variation explained by (1) population age, (2) health condition prevalence, (3) service utilization, and (4) service price and intensity.

Design, Setting, and Participants

In this cross-sectional study, data for 4 key drivers of per capita spending were extracted for 3110 US counties, 148 health conditions, 38 age-sex groups, 4 payers, and 7 types of care for 2019. Service utilization was measured as service volume per prevalent case, while price and intensity was measured as spending per visit, admission, or prescription. Das Gupta and Shapley decomposition methods and linear regression were used to estimate the contribution of each factor. The data analysis was conducted between March 2024 and July 2024.

Exposures

Age, disease prevalence, service utilization, or service price and intensity.

Main Outcomes and Measures

Variation in health care spending across US counties.

Results

In 2019, 76.6% of personal health care spending was included in this study. Overall, 64.8% of cross-county health care spending variation among 3110 US counties was explained by service utilization, while population age, disease prevalence, and price and intensity of services explained 4.1%, 7.0%, and 24.1%, respectively. The rate at which these factors contributed to variation in spending differed by payer, type of care, and health condition. Service utilization was associated with insurance coverage, median income, and education. An increase in each of these from the median to the 75th percentile was associated with a 7.8%, 4.4%, and 3.8% increase in ambulatory care utilization, respectively. The fraction of Medicare beneficiaries with Medicare Advantage was associated with less utilization. An increase in Medicare Advantage coverage from the median to the 75th percentile was associated with a 1.9% decrease in ambulatory care utilization. Differences in cross-state spending levels were also attributed to different factors. For Utah, the state with the least health care spending per capita, spending rates were lower for all types of care due principally to the young age profile. For New York, the state with the highest spending, spending rates were relatively high for hospital inpatient and prescribed pharmaceutical spending. For both types of care, high service price and intensity contributed to the above-average spending.

Conclusions and Relevance

In this cross-sectional study, variation in health care spending among US counties was largely related to variation in service utilization. Understanding the drivers of spending variation in the US may help policymakers assess the allocation of health care resources.