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Friedman C, Luxama CM. Mental and Behavioral Health, and Crisis Services for People with Intellectual and Developmental Disabilities in Medicaid Home- and Community-Based Services. J Autism Dev Disord 2024:10.1007/s10803-024-06441-z. [PMID: 38951311 DOI: 10.1007/s10803-024-06441-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/03/2024]
Abstract
People with intellectual and developmental disabilities (IDD) often have higher rates of comorbid mental health conditions compared to the general population. Yet, many people with IDD also have unmet needs for mental and behavioral health services. The aim of this study was to examine how states provided mental and behavior health, and crisis services to people with IDD in their Home- and Community-Based Services (HCBS) programs, the largest funding mechanism for Long-Term Services and Supports (LTSS) for people with IDD in the United States. We analyzed fiscal year (2021) Medicaid HCBS waivers for people with IDD from across the United States to examine if and how they provided mental and behavior health, and crisis services. States projected spending $968.9 million for mental and behavior health, and crisis services for 190,299 people with IDD. Applied behavior analysis services were provided at greater rates than positive behavior supports and other forms of behavior interventions. While most states provided mental and behavior health, and crisis services in their waivers, there were vast inconsistencies in how they did so, across states, waivers, and services. HCBS are a crucial safety net to ensure people with IDD, especially those who also have mental health disabilities, can live and thrive in their communities.
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Affiliation(s)
- Carli Friedman
- The Council on Quality and Leadership (CQL), 100 West Road, Suite 300, Towson, MD, 21204, USA.
| | - Carine M Luxama
- College of Nursing and Health Services, University of Massachusetts at Boston, 100 Morrissey Blvd, Boston, MA, 02125, USA
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2
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Gallin Z, Kolevzon AM, Reichenberg A, Hankerson SH, Kolevzon A. Racial Differences in the Prevalence of Autism Spectrum Disorder: A Systematic Review. J Autism Dev Disord 2024:10.1007/s10803-024-06403-5. [PMID: 38941049 DOI: 10.1007/s10803-024-06403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Racial differences in prevalence rates of autism spectrum disorder (ASD) have shifted in the United States (US) since the 1990s. This review addresses the nature and context of this shift and discusses potential contributing factors and areas for future research. METHODS Seventeen population-based epidemiological birth cohort studies on ASD prevalence in the US that included race as a variable are included in the review. Studies were identified via a keyword search on PubMed. To be included, studies were required to include race or ethnicity as a variable in the prevalence estimates, include at least 1000 cases with autism, and be published in English by June 3rd, 2023. RESULTS Results suggest that in nearly all birth cohorts prior to 2010, ASD prevalence rates were highest among White children. ASD prevalence rates among Black, Hispanic, and Asian/Pacific Islander (API) children (22.3, 22.5, and 22.2 per 1000, respectively) surpassed prevalence rates among White children (21.2 per 1000) in the 2010 birth cohort and continued to increase in the 2012 birth cohorts. CONCLUSIONS There are persistent racial differences in ASD prevalence in the US, and these differences were inverted after 2010, when ASD prevalence among Black, Hispanic, & API children surpassed ASD prevalence among White children. Possible drivers of this racial repatterning of ASD prevalence include changes in ASD screening and diagnosis, changes to health insurance policy, changes to immigration policy, and increased education attainment by minority groups.
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Affiliation(s)
- Zachary Gallin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Abraham Reichenberg
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sidney H Hankerson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Sciences & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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3
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Graaf G, Whitfield E, Snowden L. 1915(c) Medicaid Waivers for Children With Severe Emotional Disturbance: Participant Characteristics, Enrollment, and Out-of-Home Service Use. JOURNAL OF DISABILITY POLICY STUDIES 2023. [DOI: 10.1177/10442073231157347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Several states have invested in 1915(c) Home and Community Based Service (HCBS) Medicaid policies to improve outcomes and reduce costs for children and youth with significant behavioral health needs, or Severe Emotional Disturbance (SED). However, little is known about these programs and the children they serve. Through a retrospective cross-sectional analysis, this study aimed to understand if the program was successfully reaching its target population: children and youth with the highest clinical need, at the greatest risk for out-of-home care, and who may not otherwise be eligible for Medicaid through other avenues. Results describe the demographic, clinical, and service use characteristics of children and youth enrolled in one SED Waiver program, comparing them with those of similar, non-waiver enrolled children with behavioral health needs. Findings report that the waiver program examined rarely served children and families not otherwise eligible for Medicaid, but that waiver-enrolled children and youth had substantially more severe clinical need, were at higher risk for out-of-home placement and incurred greater public expenditures for service use. Findings suggest the program studied is serving children with more significant psychiatric needs, as the program intends, but points to the need for further research to understand the impacts of such programs on system and clinical outcomes.
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Shea L, Tao S, Marcus SC, Mandell D, Epstein AJ. Medicaid Disruption Among Transition-Age Youth on the Autism Spectrum. Med Care Res Rev 2022; 79:525-534. [PMID: 34632834 PMCID: PMC10775849 DOI: 10.1177/10775587211051185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age.
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Affiliation(s)
| | - Sha Tao
- Drexel University, Philadelphia, PA, USA
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5
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Graaf G, Baiden P, Boyd G, Keyes L. Barriers to Respite Care for Children with Special Health Care Needs. J Dev Behav Pediatr 2022; 43:117-129. [PMID: 34310466 DOI: 10.1097/dbp.0000000000000992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to estimate time-specific, population-based prevalence of 14 specific barriers to respite services, as reported by parents of children with special health care needs (CSHCN) with and without emotional, behavioral, or developmental problems (EBDPs), and to identify individual, family, and environmental characteristics associated with the most common barriers to respite care for families of CSHCN. METHODS Descriptive, bivariate, and multivariable logistic regression analyses were used to examine data from the National Survey of Children with Special Health Care Needs for 2005/2006 and 2009/2010. RESULTS Among families reporting unmet need for respite care services, service availability or transportation barriers (23.8%) and cost barriers (19.8%) were the most commonly reported obstacles among all CSHCN, followed by lack of knowledge about where to obtain respite services (12.1%) and inconvenient service times (11.3%). Reports of location or availability barriers decreased significantly from 2005 to 2009, but service time barriers increased simultaneously. All types of barriers to respite services were reported significantly more frequently by CSHCN with EBDPs than those without, even when other demographic factors were controlled for. CSHCN conditional severity and discontinuity in insurance were positively associated with cost barriers, whereas CSHCN public health coverage was associated with reduced rates of reported cost and information barriers to respite care. CONCLUSION Increased understanding of parent-reported barriers to respite care for families of CSHCN is critical to creating structural and practice-oriented solutions that address obstacles and increase access to respite care for these vulnerable families.
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Affiliation(s)
- Genevieve Graaf
- School of Social Work, University of Texas at Arlington, Arlington, TX
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6
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Song W, Salzer MS, Nonnemacher SL, Shea L. Lifespan service receipt and unmet needs among individuals on the autism spectrum. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:694-705. [PMID: 35320442 DOI: 10.1007/s10488-022-01192-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 01/18/2023]
Abstract
Timely data on service use and needs across the lifespan are essential to developing an effective and efficient service delivery system that is responsive to developmental issues. This study uses data from one of the largest statewide surveys conducted between 2017 and 2018 to compare service use and unmet needs among individuals on the autism spectrum across the lifespan. A statewide sample of 5792 caregivers of autistic children and adults were included in the study. Logistic regressions were conducted to compare service use and need among six age groups ranging from early childhood (0-5 years) to later adulthood (31+) while adjusting for sociodemographic characteristics. We found that the transition-age adult group (18-21 years) was less likely to receive services, including speech/language therapy, occupational therapy, one-on-one support, and social skill training, than adolescents. However, case management and mental health services increased with age. Young adults (22-30 years) were more likely to report unmet needs than both adolescents and transition-age adult groups. The use of services overall decrease and service needs increased compared to results from an earlier statewide survey that was conducting in 2009-2010. These results can be used to inform developmentally appropriate autism-related healthcare policies and service development and delivery. This study offers a more detailed look at differences between adult age subgroups that are novel. Further research is needed about the prevalence of ASD in adulthood, clinical trajectories, and outcomes in order to support autistic adults in getting the appropriate services and supports.
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Affiliation(s)
- Wei Song
- College of Public Health, Temple University, 1700 N. Broad St., Suite 313, 19122, Philadelphia, PA, USA.
| | - Mark S Salzer
- Temple University Collaborative on Community Inclusion of Individuals with, Psychiatric Disabilities, 1700 N. Broad St., Suite 304, 19122, Philadelphia, PA, USA
| | - Stacy L Nonnemacher
- Bureau of Supports for Autism and Special Populations, Department of Human Services, 801 Market St, 19107, Philadelphia, Pennsylvania, PA, USA
| | - Lindsay Shea
- Policy and Analytics Center, A.J. Drexel Autism Institute, Drexel University, 3020 Market Street, Suite 560, 19104, Philadelphia, PA, USA
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Lindly O, Eaves MC, Xu Y, Tarazi CL, Rao SR, Kuhlthau KA. Therapy use for U.S. school-aged children with developmental disabilities: State variation and determinants. Disabil Health J 2022; 15:101198. [PMID: 34489204 PMCID: PMC8812207 DOI: 10.1016/j.dhjo.2021.101198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Therapy services can support developmental needs, improve social emotional outcomes, and reduce persistent health inequities for children with developmental disabilities (DD). Receipt of therapy services may be especially timely when children with DD are school-aged, once diagnosis has often occurred. Yet limited knowledge exists on geographic variability and determinants of therapy use among school-aged U.S. children with DD. OBJECTIVES We aimed to (1) determine if therapy use varies significantly by state and (2) examine associations of health determinants with therapy use among U.S. school-aged children with DD. METHODS This was a secondary analysis of 2016 and 2017 National Survey of Children's Health data. The sample included 9984 children with DD ages 6-17 years. We obtained odds ratios and predicted margins with 95% confidence intervals from multilevel logistic regression models to examine therapy use variation and determinants. RESULTS Overall, 34.6% of children used therapy services. Therapy use varied significantly across states (σ2 = 0.11, SE = 0.04). Younger age, public insurance, functional limitations, individualized education program, frustration accessing services, and care coordination need were associated with higher adjusted odds of therapy access. In states with Medicaid Home and Community-Based Services waivers, higher estimated annual waiver cost was associated with lower adjusted odds of therapy use. CONCLUSIONS Results highlight geographic disparities in therapy use and multilevel targets to increase therapy use for school-aged children with DD.
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Affiliation(s)
- Olivia Lindly
- Department of Health Sciences, Northern Arizona University, 1100 S. Beaver Street Room 488, Flagstaff, AZ, 86011, United States.
| | - Megan C Eaves
- School of Social Work, Boston University, 264 Bay State Road, Boston, MA, 02215, United States.
| | - Yue Xu
- Department of Disabilities and Human Development, University of Illinois at Chicago, 1640 Roosevelt Road, Chicago, IL, 60608, United States.
| | - Chelsey L Tarazi
- Combined Counseling/School Psychology Program, Northern Arizona University, 801 Knoles Drive, Flagstaff, AZ, 86011, United States.
| | - Sowmya R Rao
- Massachusetts General Hospital Biostatistics Center, 50 Staniford Street, Boston, MA, 02114, United States; Department of Global Health, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, United States.
| | - Karen A Kuhlthau
- Division of Pediatric Health Outcomes Research, Massachusetts General Hospital, 125 Nashua Street, Boston, MA, 02114, United States; Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, United States.
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8
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Choi KR, Bhakta B, Knight EA, Becerra-Culqui TA, Gahre TL, Zima B, Coleman KJ. Patient Outcomes After Applied Behavior Analysis for Autism Spectrum Disorder. J Dev Behav Pediatr 2022; 43:9-16. [PMID: 34342287 PMCID: PMC8702444 DOI: 10.1097/dbp.0000000000000995] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 04/21/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The purpose of this study was to examine patterns of service receipt and patient outcomes for children receiving applied behavior analysis (ABA) for autism spectrum disorder (ASD) in an integrated health care system in which commercially insured children were covered by a state autism mandate. METHODS This retrospective, observational study used a random sample of children with ASD (3-17 yrs) who were members of a large integrated health care system in Southern California and referred for ABA between January 2016 and November 2018. From the 4145 children referred, a random stratified sample of 334 was selected to extract data from clinical reports over 24 months of services. The primary outcome measures were time in ABA and child adaptive behavior. RESULTS Thirteen percent of the sample never received ABA after referral. Of those who were referred for ABA, 66% initiated ABA and remained in services for 12 months, whereas less than half (46%) remained in services for 24 months. Having a history of special education was associated with longer time spent in ABA, whereas having a single parent was associated with discontinuation of ABA. A minority of children received a full ABA dose (28%), but the lowest functioning children still experienced clinically significant adaptive behavior gains after 24 months of ABA (p = 0.02). CONCLUSION In a health system implementation of ABA for children with ASD, there were high rates of ABA discontinuation and low ABA dosing. These challenges may diminish the potential benefits of ABA, even in a context in which there is mandated commercial insurance coverage.
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Affiliation(s)
- Kristen R. Choi
- School of Nursing, University of California, Los Angeles, Los Angeles, California
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Bhumi Bhakta
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | | | - Tracy A. Becerra-Culqui
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
- Southern California Permanente Medical Group, Kaiser Permanente, Pasadena, CA
| | - Teri L. Gahre
- Southern California Permanente Medical Group, Kaiser Permanente, Pasadena, CA
| | - Bonnie Zima
- Center for Health Services and Society, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, California
| | - Karen J. Coleman
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
- Southern California Permanente Medical Group, Kaiser Permanente, Pasadena, CA
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9
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Holingue C, Jang Y, Azad G, Landa R. Key stakeholder perspectives on obstacles to an autism-specific Medicaid waiver service delivery model. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2021; 35:205-216. [PMID: 34558157 DOI: 10.1111/jar.12940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 08/27/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children and youth with autism spectrum disorder have significant, multi-system needs that require supports, such as the autism waiver (AW) service delivery model. This study aimed to identify and describe characteristics of the AW, define obstacles and strengths in the provision of adequate services and provide recommendations for improving overall effectiveness. METHODS This mixed-methods exploratory study used an electronic survey to gain information and perceptions of AW provider agency directors (n = 27) and service coordinators (n = 30). RESULTS The key barriers reported were the shortage of qualified staff, inadequate staff training, complexity of cases or symptom severity of clients and lack of communication at multiple levels throughout the agency as well as with parents. CONCLUSIONS Recommendations include reinforcing the workforce through higher salaries, greater training and communication interventions. These strategies may reduce staff turnover and shortage, lighten the caseload, reduce the waitlist period and improve the effectiveness and responsiveness of AW services.
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Affiliation(s)
- Calliope Holingue
- Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yeon Jang
- Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Gazi Azad
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University, New York, New York, USA.,Center for Autism and the Developing Brain, Weill Cornell Medicine, New York State Psychiatric Institute, New York, New York, USA
| | - Rebecca Landa
- Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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10
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Assessing the Healthy People 2020 Objective to Expand Early Treatment Receipt Among a National Sample of Children with Autism Spectrum Disorder. J Dev Behav Pediatr 2021; 41:359-365. [PMID: 32168260 DOI: 10.1097/dbp.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the progress of the Healthy People 2020 (HP2020) objective to increase the proportion of children with autism spectrum disorder (ASD) who receive treatment by 48 months old and to examine the relationship between predisposing, enabling, and need factors and age of initial treatment receipt. METHOD We used data from the National Survey of Children's Health, 2016 to 2017, a nationally representative study of US children. Our sample included children aged 3 to 17 years old with ASD who received treatment (N = 1333). We conducted χ goodness of fit tests and logistic regression. RESULTS The HP2020 objective to enroll 57.6% of 8-year-old children with ASD in treatment by 48 months old was not met (40.9%). Among 3- to 5-year-old children with ASD, the proportion who received treatment by 48 months old was more than double that of 8-year-old children (88.3%). We detected social inequities and significant differences by provider type and state mandate. CONCLUSION Research with larger samples is needed to continue tracking progress. If the goal continues not to be met, work will be required to explain stagnation and to inform additional targeted efforts to reduce the age of initial treatment.
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Shea LL, Koffer Miller KH, Verstreate K, Tao S, Mandell D. States' use of Medicaid to meet the needs of autistic individuals. Health Serv Res 2021; 56:1207-1214. [PMID: 34251042 DOI: 10.1111/1475-6773.13671] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the use of Medicaid programs, including waivers, to address the needs of aging autistic individuals. DATA SOURCES We gathered data on Medicaid programs in place between 2004 and 2015 for 50 states and the District of Columbia from the Centers for Medicare and Medicaid Services website, by contacting state Medicaid administrators and advocacy groups, and by reviewing the Medicaid Analytic eXtract Waiver Crosswalk. STUDY DESIGN This retrospective analysis classified each Medicaid program and documented state changes over time in eligibility criteria: those serving autism spectrum disorder only, autism spectrum disorder or intellectual disability, and intellectual disability only. DATA COLLECTION/EXTRACTION METHODS We captured age and diagnosis eligibility criteria for Medicaid programs serving any of the three target groups. PRINCIPAL FINDINGS A total of 269 Medicaid programs met our criteria and most programs (51%) were 1915(c) waivers. The number of autism-specific 1915(c) waivers grew more than fivefold during the study period, outpacing increases in waivers serving individuals with intellectual disability. CONCLUSIONS States varied in their use of Medicaid to address the needs of the aging autism population. Further study of characteristics of states that changed their Medicaid programs, and of the health care use and outcomes associated with these changes, are needed to identify opportunities to replicate effective approaches to meeting the needs of this population.
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Affiliation(s)
- Lindsay Lawer Shea
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Kate Verstreate
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
| | - Sha Tao
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
| | - David Mandell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Karpur A, Vasudevan V, Lello A, Frazier TW, Shih A. Food insecurity in the households of children with autism spectrum disorders and intellectual disabilities in the United States: Analysis of the National Survey of Children's Health Data 2016-2018. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2021; 25:2400-2411. [PMID: 34075809 DOI: 10.1177/13623613211019159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
LAY ABSTRACT Families of children with autism spectrum disorder are more likely to experience financial strain and resulting food insecurity due to additional cost of care, disparate access to needed services, and loss of income resulting from parental job loss. Utilizing nationally representative data, this analysis indicates that the families of children with autism spectrum disorder and co-occurring intellectual disabilities are twice as likely to experience food insecurity than families of children without disabilities after adjusting for various factors. Several factors, ranging from state-level policies such as Medicaid expansion to individual-level factors such as higher utilization of emergency room services, were associated with the higher prevalence of food insecurity in families of children with autism spectrum disorder and co-occurring intellectual disabilities. Implications of these findings on programs and policies supporting families in the COVID-19 pandemic are discussed.
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Schott W, Nonnemacher S, Shea L. Service Use and Unmet Needs Among Adults with Autism Awaiting Home- and Community-Based Medicaid Services. J Autism Dev Disord 2021; 51:1188-1200. [PMID: 32671666 DOI: 10.1007/s10803-020-04593-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Autistic adults in need of long-term services and supports spend months on waiting lists before receiving such services through Medicaid. Data from a state-wide survey of adults and their caregivers on a waiting list for autism waivers suggest that the majority have unmet needs for functional skills services (63.6%), employment or vocation services (62.1%), and mental and behavioral health services (52.8%). Almost a third require case management services (28.3%). Predictors of greater service need are African American race and the number of physical and behavioral health diagnoses. Predictors of greater service receipt were employment status, housing type, and school enrollment; there was lower service receipt for African American race, Hispanic ethnicity, over age 21 years, and college completion.
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Affiliation(s)
- Whitney Schott
- Policy and Analytics Center, A.J. Drexel Autism Institute, Drexel University, 3020 Market Street, Suite 560, Philadelphia, PA, 19104, USA.
| | - Stacy Nonnemacher
- Bureau of Supports for Autism and Special Populations, Pennsylvania Department of Human Services, 801 Market St., Philadelphia, PA, 19107, USA
| | - Lindsay Shea
- Policy and Analytics Center, A.J. Drexel Autism Institute, Drexel University, 3020 Market Street, Suite 560, Philadelphia, PA, 19104, USA
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14
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Liu G, Velott DL, Kong L, Dick AW, Mandell DS, Stein BD, Murray MJ, Ba DM, Cidav Z, Leslie DL. The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder. J Autism Dev Disord 2021; 52:1587-1597. [PMID: 33966133 DOI: 10.1007/s10803-021-05060-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.
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Affiliation(s)
- Guodong Liu
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA.
| | - Diana L Velott
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Lan Kong
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Andrew W Dick
- The RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - David S Mandell
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Bradley D Stein
- The RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Michael J Murray
- Department of Psychiatry, College of Medicine, Pennsylvania State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Djibril M Ba
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Zuleyha Cidav
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Douglas L Leslie
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
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Service Use Among Transition-Age Youth with Autism Spectrum Disorder. J Autism Dev Disord 2021; 52:1051-1065. [PMID: 33864557 DOI: 10.1007/s10803-021-04999-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
This study explored predictors of service use among 174 transition-age youth (age 16-30) with an Autism Spectrum Disorder using Andersen's (J Health Soc Behav 36(1):1-10, 1995) healthcare utilization model. Family caregivers were interviewed about past 6-month use of 15 services. On average, youth used 6.1 and needed 3.2 additional services. Greater service use was associated with two predisposing (caregiver college educated, caregiver not married/partnered), two enabling (youth has Medicaid waiver, youth in high school), and one need factor (lower adaptive functioning). Use of specific services was most strongly related to enabling (Medicaid waiver, in high school) and need factors (lower adaptive functioning, comorbid mental health diagnosis). Findings provide a snapshot of the "service cliff" faced by families and highlight the need for additional research.
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Yingling ME, Ruther MH, Dubuque EM, Mandell DS. County-level variation in geographic access to Board Certified Behavior Analysts among children with Autism Spectrum Disorder in the United States. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2021; 25:1734-1745. [PMID: 33740869 DOI: 10.1177/13623613211002051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
LAY ABSTRACT This study looked at whether access to Board Certified Behavior Analysts for children with autism spectrum disorder is different between U.S. counties. The study included all U.S. counties and county equivalents in 48 states and D.C. (N = 3108). Between March and May 2019, we combined data from the U.S. Department of Education's Civil Rights Data Collection, Behavior Analyst Certification Board's certificant registry, and U.S. Census. We assigned Board Certified Behavior Analysts to counties based on their address, matched children in school districts to counties, and determined how many children with autism spectrum disorder there were in a county compared with how many Board Certified Behavior Analysts there were in a county. The results show uneven numbers of Board Certified Behavior Analysts between U.S. counties. More than half of all counties had no Board Certified Behavior Analysts. National maps illustrate clusters of high and low accessibility to Board Certified Behavior Analysts. To improve access to Board Certified Behavior Analysts in underserved areas, we must identify what contributes to the differences in access.
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Choi KR, Knight EA, Stein BD, Coleman KJ. Autism Insurance Mandates in the US: Comparison of Mandated Commercial Insurance Benefits Across States. Matern Child Health J 2021; 24:894-900. [PMID: 32356129 DOI: 10.1007/s10995-020-02950-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Autism mandates are laws that require commercial insurers to cover certain evidence-based treatments for Autism Spectrum Disorder (ASD). The purpose of this study was to review state variability in autism insurance mandates and the benefits they cover and to discuss recommendations for research and policy to improve ASD services across states. METHODS Data were extracted from 2001 to 2020 from all 50 states plus the District of Columbia (N = 51) from policy text. News articles and websites of ASD advocacy organizations were also reviewed to ensure inclusion of the most recent policy changes. Descriptive statistics and heatmaps were used to characterize the autism mandate landscape and visualize variability in benefit parameters across states. RESULTS Autism mandates vary greatly in benefit parameters across US states, but there is a common set of benefits that most states have adopted. These include coverage of provider-recommended ASD services except for medical equipment, coverage up to an age limit of 18 to 21, an annual dollar limit of $36,000 with no restriction on the number of hours or visits, no lifetime cap on benefits, and requirement of BCBA® certification or its equivalent for providers of ABA. DISCUSSION There is a need for continued research evaluating the impact of autism mandates and benefit parameters on access to care, service utilization, and clinical outcomes for the ASD population. Stakeholder engagement and understanding the impact of autism mandates on clinical and patient-centered outcomes may provide direction for policy advocacy and public health initiatives.
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Affiliation(s)
- Kristen R Choi
- UCLA School of Nursing, 700 Tiverton Ave, Factor Bldg Room 3-238, Los Angeles, CA, 90095, USA. .,Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101-2453, USA.
| | - Elizabeth A Knight
- Utility for Care Data Analysis, Kaiser Foundation Health Plan, Program Office, One Kaiser Plaza - 21 Bayside, Oakland, CA, 94612, USA
| | - Bradley D Stein
- RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA
| | - Karen J Coleman
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101-2453, USA
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Hyman SL, Levy SE, Myers SM. Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics 2020; 145:peds.2019-3447. [PMID: 31843864 DOI: 10.1542/peds.2019-3447] [Citation(s) in RCA: 482] [Impact Index Per Article: 120.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child's function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions. This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.
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Affiliation(s)
- Susan L Hyman
- Golisano Children's Hospital, University of Rochester, Rochester, New York;
| | - Susan E Levy
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Scott M Myers
- Geisinger Autism & Developmental Medicine Institute, Danville, Pennsylvania
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Yingling ME, Bell BA, Hock RM. Comparing Neighborhoods of Children With Autism Spectrum Disorder in a Medicaid Waiver Program and a State Population, 2007-2015. Psychiatr Serv 2019; 70:1034-1039. [PMID: 31378192 DOI: 10.1176/appi.ps.201800479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study investigated equity in enrollment in a Medicaid waiver program for early intensive behavioral intervention for children with autism spectrum disorder (ASD). METHODS State administrative, Medicaid, and U.S. Census data for children enrolled in the waiver program between 2007 and 2015 (N=2,111) were integrated. Multivariate and bivariate analyses were used to compare enrollees' neighborhood demographic characteristics with those of the state's general population, with controls for enrollees' age, sex, and race-ethnicity. RESULTS Findings indicate that in general, enrollment was equitable. During the years in which there were inequities, children who lived in neighborhoods of privilege were favored. These neighborhoods had higher median incomes, lower poverty levels, and fewer female-headed households and were located in urban areas. CONCLUSIONS As states work to provide equitable treatment to children with ASD and their families, it is important to track potential inequities between children who do and do not enroll in services and to use this information to inform outreach efforts. States may turn to South Carolina for insight on how to ensure equity.
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Affiliation(s)
- Marissa E Yingling
- Kent School of Social Work, University of Louisville, Louisville, Kentucky (Yingling); College of Social Work, Hamilton College, University of South Carolina, Columbia (Bell, Hock)
| | - Bethany A Bell
- Kent School of Social Work, University of Louisville, Louisville, Kentucky (Yingling); College of Social Work, Hamilton College, University of South Carolina, Columbia (Bell, Hock)
| | - Robert M Hock
- Kent School of Social Work, University of Louisville, Louisville, Kentucky (Yingling); College of Social Work, Hamilton College, University of South Carolina, Columbia (Bell, Hock)
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20
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Rubenstein E, Croen L, Lee LC, Moody E, Schieve LA, Soke GN, Thomas K, Wiggins L, Daniels J. Community-based service use in preschool children with autism spectrum disorder and associations with insurance status. RESEARCH IN AUTISM SPECTRUM DISORDERS 2019; 66:101410. [PMID: 32831903 PMCID: PMC7430759 DOI: 10.1016/j.rasd.2019.101410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND ASD-related services can improve outcomes for children, but less is known about service outside of school settings during preschool age. We aimed to describe amount and category of community-based service use among 3-5-year-old children with ASD and examine differences by health insurance. METHODS We used cross-sectional data on 792 children with ASD diagnoses in the Study to Explore Early Development, a community-based study of neurodevelopment with enrollment between 2012-2016. Mothers reported current child service use and insurance status at study entry. We used log-Poisson and logistic regression to compare service use by insurance group. RESULTS Nearly 40% of children were not receiving community-based services at study entry. Children with public insurance had fewer total services than children with private or both insurances. After adjustment for sociodemographic confounders, insurance status was not associated with types of different categories of community-based services. However, children with public insurance alone were least likely to receive community-based behavioral therapy and most likely to receive psychotropic medication compared to other insurances. CONCLUSION Many preschool-aged children do not receive community-based services, with receipt associated with insurance type. Increasing access and availability for evidence-based service, especially for beneficiaries of public insurance, may improve service use and outcomes.
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Affiliation(s)
- Eric Rubenstein
- University of Wisconsin Madison, Waisman Center, 1500 Highland Ave, Madison WI, 53705
| | - Lisa Croen
- Division of Research, Kaiser Permanente of Northern California, 2000 Broadway, Oakland, CA 94612
| | - Li-Ching Lee
- Bloomberg School of Public Health, Johns Hopkins University, 315 N Wolfe St, Baltimore, MD 21231
| | - Eric Moody
- Wyoming Institute of Disabilities, University of Wyoming, 1000 E. University Ave. Laramie, WY 82071
| | - Laura A. Schieve
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, 1600 Clifton Road, Atlanta, GA 30329
| | - Gnakub N. Soke
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, 1600 Clifton Road, Atlanta, GA 30329
| | - Kathleen Thomas
- Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, 725 Martin Luther King Jr. Blvd. Chapel Hill, NC 27599-7590
| | - Lisa Wiggins
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, 1600 Clifton Road, Atlanta, GA 30329
| | - Julie Daniels
- University of North Carolina Gillings School of Global Public Health, Department of Biostatistics, 137 East Franklin Street Room 6702 CB# 8030 Chapel Hill, NC 27514
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Keim-Malpass J, Constantoulakis L, Letzkus LC. Variability In States’ Coverage Of Children With Medical Complexity Through Home And Community-Based Services Waivers. Health Aff (Millwood) 2019; 38:1484-1490. [DOI: 10.1377/hlthaff.2018.05413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jessica Keim-Malpass
- Jessica Keim-Malpass is an assistant professor in the School of Nursing, University of Virginia, in Charlottesville
| | - Leeza Constantoulakis
- Leeza Constantoulakis is a research assistant in the School of Nursing, University of Virginia
| | - Lisa C. Letzkus
- Lisa C. Letzkus is a nurse scientist in the School of Nursing, University of Virginia and University of Virginia Medical Center
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22
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Benevides TW, Carretta HJ, Graves KY. Case Identification and Characterization of Autistic Young Adults in 2010 Medicare Fee-for-Service Claims. AUTISM IN ADULTHOOD 2019; 1:210-218. [PMID: 36601414 PMCID: PMC8992825 DOI: 10.1089/aut.2018.0036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Medicare is a public insurer for whom many autistic adults are eligible in the United States, but little is known about autistic beneficiaries who are covered. A challenge in using claim data is identification of autism spectrum disorder (ASD) cases to ensure accurate characterization. Some work suggests that relying on one claim could identify probable ASD, although other works indicate that two claims are necessary for case identification. The purpose of the current study was to describe the sample of Medicare young adult beneficiaries, and determine whether using a 1+ versus 2+ claim case identification resulted in similar interpretation of sample demographic characteristics and primary care utilization patterns in Medicare professional service claims. Methods We used Medicare Limited Data Sets (2008-2010) claims. After ASD case identification using ICD-9-CM (299.xx), 527 unique beneficiaries in the last claim year of 2010 professional service file were identified as having at least one claim of ASD. Of these, 69% (n = 364) had two or more claims. Proportions and zero-inflated negative binomial regression were used to examine differences in demographic characteristics and primary care utilization and costs for the 1+ and 2+ samples. Results Medicare claims contain a sample of autistic adults with expected demographics identified in historic prevalence cohorts. No differences in age, gender, race/ethnicity, Hispanic status, or dual-eligibility months or Adjusted Clinical Groups (ACG)® concurrent risk scores were identified between the 1+ and 2+ samples. No difference was found in the overall estimation of primary care use or costs between the 1+ and 2+ samples based on Zellner's seemingly unrelated regression methods. Conclusions This study is the first to describe a national sample of Medicare-insured autistic adults. We found that using a 1+ case identification results in a sample that is demographically similar to a 2+ claim sample, and produces similar estimates of utilization as a 2+ claim sample.
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Affiliation(s)
- Teal W Benevides
- Department of Occupational Therapy, College of Allied Health Sciences, Augusta University, Augusta, Georgia
| | - Henry J Carretta
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee, Florida
| | - Katelyn Y Graves
- Department of Behavioral Sciences and Social Medicine, College of Medicine, School of Physician Assistant Practice, Florida State University, Tallahassee, Florida
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23
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LaClair M, Mandell DS, Dick AW, Iskandarani K, Stein BD, Leslie DL. The effect of Medicaid waivers on ameliorating racial/ethnic disparities among children with autism. Health Serv Res 2019; 54:912-919. [PMID: 31132161 PMCID: PMC6606603 DOI: 10.1111/1475-6773.13176] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the effects of Medicaid Home and Community-based Services (HCBS) waivers on reducing racial/ethnic disparities in unmet need for services among families of children with autism spectrum disorder (ASD). DATA SOURCES Data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health and the 2005 and 2010 waves of the National Survey of Children with Special Health Care Needs were used. Data on waiver characteristics were collected from source materials that were submitted in support of each state's waiver application. Waiver characteristics were combined to create a single waiver generosity variable. STUDY DESIGN Quasi-difference-in-difference-in-difference models were used to determine the effect of waiver generosity on racial/ethnic disparities in unmet need among children with ASD. PRINCIPAL FINDINGS Increased waiver generosity was associated with significantly reduced odds of having unmet need for black children with ASD compared with white children with ASD. Unmet needs among black children with ASD were roughly cut in half, a 13 percentage point decrease, with the implementation of an average generosity waiver. No significant differences were seen for Hispanic ethnicity. CONCLUSION These findings suggest that Medicaid HCBS waivers have the potential to ameliorate disparities in unmet need among children with ASD. Future policy development should focus on replicating the most effective characteristics of these waivers.
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Affiliation(s)
- Michelle LaClair
- Department of Public Health SciencesPenn State College of MedicineHersheyPennsylvania
| | - David S. Mandell
- Department of PsychiatryUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | | | - Khaled Iskandarani
- Department of Public Health SciencesPenn State College of MedicineHersheyPennsylvania
| | - Bradley D. Stein
- RAND CorporationPittsburghPennsylvania
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Douglas L. Leslie
- Department of Public Health SciencesPenn State College of MedicineHersheyPennsylvania
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24
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Keim-Malpass J, Letzkus LC, Constantoulakis L. Publicly Funded Home and Community-Based Care for Children With Medical Complexity: Protocol for the Analysis of Medicaid Waiver Applications. JMIR Res Protoc 2019; 8:e13062. [PMID: 31344668 PMCID: PMC6686641 DOI: 10.2196/13062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 06/14/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022] Open
Abstract
Background Children with medical complexity are a group of children with multiple chronic conditions and functional limitations that represent the highest health care utilization and often require a substantial number of home and community-based services (HCBS). In many states, HCBS are offered to target populations through 1915(c) Medicaid waivers. To date, no standard methods or approaches have been established to evaluate or compare 1915(c) waivers across states in the United States for children. Objective The purpose of this analysis was to develop a systematic and reproducible approach to evaluate 1915(c) Medicaid waivers for overall coverage of children with medical complexity. Methods Data elements were extracted from Medicaid 1915(c) approved waiver applications for all included waivers targeting any pediatric age range through October 31, 2018. Normalization criteria were established, and an aggregate overall coverage score was calculated for each waiver. Results Data extraction occurred in two phases: (1) waivers that were considered nonexpired through December 31, 2017, and (2) the final sample that included nonexpired waivers through October 31, 2018. A total of 142 waivers across 45 states in the United States were included in this analysis. We found that the existing adult HCBS taxonomy may not always be applicable for child and family-based service provision. Although there was uniformity in the Medicaid applications, there was high heterogeneity in how waiver eligibility, transition plans, and wait lists were defined. Study analysis was completed in January 2019, and after analyzing each individual waiver, results were aggregated at the level of the state and for each diagnostic subgroup. The published results are forthcoming. Conclusions To our knowledge, this is the first study to systematically evaluate 1915(c) Medicaid waivers targeting children with medical complexity that can be replicated without the threat of missing data. International Registered Report Identifier (IRRID) RR1-10.2196/13062
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Affiliation(s)
| | - Lisa C Letzkus
- University of Virginia School of Nursing, Charlottesville, VA, United States
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25
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Lee JY, Yun J. What Else Is Needed in the Korean Government's Master Plan for People With Developmental Disabilities? J Prev Med Public Health 2019; 52:200-204. [PMID: 31163956 PMCID: PMC6549009 DOI: 10.3961/jpmph.18.249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/07/2019] [Indexed: 12/02/2022] Open
Abstract
On September 12, 2018, President Jae-In Moon announced the Comprehensive Plan for Lifelong Care for People with Developmental Disabilities, with representatives from the associated government branches (Ministry of Health and Welfare, Ministry of Education, and Ministry of Employment and Labor) in attendance. The goals of this plan are to provide health, medical, rehabilitative, special education, and social welfare services according to the life-stages of the affected individuals; to reduce parental pressure; to promote social interventions; and to enhance community-level participation in order to create a ‘welfare society in harmony.’ However, in order for the plan to succeed, additional efforts must be made in the following areas. First, an epidemiological survey is needed to understand the scale, prevalence, and incidence of developmental disabilities and to establish an evidence base to support policy development. Second, accurate definitions of developmental disabilities must be established in order to avoid policy discrimination based on impairment type and age. Third, personal evaluations to assess disabled individuals’ unmet needs and customized service designs to deliver those needs are required. Fourth, the plan must fulfill the goals of accessibility and fairness that the government intends to provide. Fifth, the government should consider an integrated financial support system and to propose a detailed plan for monetary distributions. Finally, an integrated system that links health, medical, employment, educational, and welfare services must be constructed.
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Affiliation(s)
- Jin Yong Lee
- Department of Public Health and Community Medicine, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea.,Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
| | - Jieun Yun
- Department of Pharmaceutical Engineering, Cheongju University, Cheongju, Korea
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The Role of Choice and Control in the Impact of Autism Waiver Services on Family Quality of Life and Child Progress. J Autism Dev Disord 2019; 49:2035-2048. [DOI: 10.1007/s10803-019-03886-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Wang L, Ma J, Dholakia R, Howells C, Lu Y, Chen C, Li R, Murray M, Leslie D. Changes in Healthcare Expenditures After the Autism Insurance Mandate. RESEARCH IN AUTISM SPECTRUM DISORDERS 2019; 57:97-104. [PMID: 31440305 PMCID: PMC6706245 DOI: 10.1016/j.rasd.2018.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND In recent years, most U.S. states have passed autism mandates requiring private insurers to cover autism spectrum disorders (ASD). Little is known about the post-mandate changes in healthcare expenditures. METHOD This study utilized 2006-2012 de-identified insurance claims data from the largest insurer in Pennsylvania (PA), where the mandate went into effect in 2009. Healthcare expenditures were defined as the amount the insurer paid for healthcare services and were adjusted to 2012 price level. A mixed model approach was used to analyze the expenditures. RESULTS A total of 9,471 children with ASD were included in the study. Although the pre-mandate total expenditures per child with ASD were similar, the post-mandate expenditures significantly increased for groups subject to the autism mandate (87% increase from $7,754 in 2008 to $14,486 in 2010) compared to the exempt groups (27% increase from $7,238 to $9,171). By insurance type, the change from 2008 to 2010 in ASD-related expenditures per child with ASD was $8,439 for fully insured large employer sponsored plans and $43 for the Children's Health Insurance Program (CHIP), both subject to the PA mandate; and $2,631 for the self-insured, $980 for small-employers, and $-92 for individual plans, all of which are exempt from the mandate. These increases were due to outpatient services but not inpatient or drug costs. CONCLUSIONS Healthcare expenditures increased significantly following the PA autism mandate. Nonexempt, large employer groups had the largest increase in spending. Some exempt, self-insured companies may have voluntarily covered ASD services, leading to a moderate increase.
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Affiliation(s)
- Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Statistics, Penn State University, University Park, PA
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA
| | - Junyi Ma
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Ruchita Dholakia
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Callie Howells
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Yun Lu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Chen Chen
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Runze Li
- Department of Statistics, Penn State University, University Park, PA
| | - Michael Murray
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA
| | - Douglas Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA
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Health Disparities among Children with Autism Spectrum Disorders: Analysis of the National Survey of Children’s Health 2016. J Autism Dev Disord 2018; 49:1652-1664. [DOI: 10.1007/s10803-018-3862-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Eskow KG, Summers JA. Family perceptions of the impacts of a home and community based services autism waiver: Making family life possible. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2018; 32:159-171. [PMID: 30151875 DOI: 10.1111/jar.12518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 07/17/2018] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND An important mechanism that provides support and services for families with a child/youth with autism spectrum disorder is the home- and community-based services (HCBS) Waiver authorized by Section 1915(c) of the Social Security Act or Medicaid. METHODS This study used qualitative research methods to explore parent perspectives about the impact of HCBS Waiver services on the child/youth with autism and their family. In-depth interviews focused on aspects of the programme they valued, identification of barriers and general issues they experienced. RESULTS Results of the qualitative study indicated that improved outcomes could be explained by providers of services who were well-trained, flexible and allowed parents' opportunities for choice regarding provision of services to meet child/youth and family needs. CONCLUSION The findings of this study provide guideposts for further research about factors that contribute to satisfaction of families receiving waiver services for quality of life and child progress.
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Affiliation(s)
| | - Jean Ann Summers
- Research & Training Center on Independent Living, Life Span Institute, University of Kansas, Lawrence, Kansas
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30
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Yingling ME, Bell BA. Racial-ethnic and neighborhood inequities in age of treatment receipt among a national sample of children with autism spectrum disorder. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2018; 23:963-970. [PMID: 30112915 DOI: 10.1177/1362361318791816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The aim of this study is to examine the impact of child race-ethnicity and neighborhood characteristics on age of treatment receipt among children with autism spectrum disorder. Here, we included 1309 children diagnosed with autism spectrum disorder in the National Survey of Children's Health, 2011-2012. Controlling for key covariates, we used a weighted generalized logit model to analyze differences in age of treatment receipt (<2 years, 2 years, 3 years, and ⩾4 years). Compared to non-Hispanic White children, the relative probability (odds) of entering treatment at 3 years and ⩾4 years rather than <2 years was 326% and 367% higher, respectively, for non-Hispanic Black children. Compared to children whose parents perceived their neighborhood to be cohesive, the relative probability of entering treatment at 2 years and 3 years rather than <2 years was 59% and 61% lower, respectively, for children whose parents did not. Significant racial-ethnic and neighborhood inequities exist in age of treatment receipt, suggesting a need for research that explores the underlying causal mechanisms of inequities.
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31
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Leslie DL, Iskandarani K, Velott DL, Stein BD, Mandell DS, Agbese E, Dick AW. Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working. Health Aff (Millwood) 2018; 36:282-288. [PMID: 28167717 DOI: 10.1377/hlthaff.2016.1136] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Several states have passed Medicaid home and community-based services waivers that expand eligibility criteria and available services for children with autism spectrum disorder. Although previous research has shown considerable variation in these waivers, little is known about the programs' impact on parents' workforce participation. We used nationally representative survey data combined with detailed information on state Medicaid waiver programs to determine the effects of waivers on whether parents of children with autism spectrum disorder had to stop working because of the child's condition. Increases in the Medicaid home and community-based services waiver cost limit and enrollment limit significantly reduced the likelihood that a parent had to stop working, although the results varied considerably by household income level. These findings suggest that the Medicaid waivers are effective policies to address the care-related needs of children with autism spectrum disorder.
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Affiliation(s)
- Douglas L Leslie
- Douglas L. Leslie is a professor at the Penn State College of Medicine, in Hershey
| | - Khaled Iskandarani
- Khaled Iskandarani is a research data analyst at the Penn State College of Medicine
| | - Diana L Velott
- Diana L. Velott is a senior instructor at the Penn State College of Medicine
| | - Bradley D Stein
- Bradley D. Stein is a senior behavioral and policy sciences researcher at the RAND Corporation in Pittsburgh, Pennsylvania
| | - David S Mandell
- David S. Mandell is director of the Center for Mental Health Policy and Services Research at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia
| | - Edeanya Agbese
- Edeanya Agbese is a project manager at the Penn State College of Medicine
| | - Andrew W Dick
- Andrew W. Dick is a senior economist at the RAND Corporation in Boston, Massachusetts
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Leslie DL, Iskandarani K, Dick AW, Mandell DS, Yu H, Velott D, Agbese E, Stein BD. The Effects of Medicaid Home and Community-based Services Waivers on Unmet Needs Among Children With Autism Spectrum Disorder. Med Care 2017; 55:57-63. [PMID: 27547947 DOI: 10.1097/mlr.0000000000000621] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Several states have passed Medicaid Home and Community-based Services (HCBS) waivers that expand eligibility criteria and available services for children with autism spectrum disorder (ASD). Previous research has shown considerable variation in these waivers, but little is known about the extent to which they address the health care needs of children with ASD. OBJECTIVE To determine the effects of Medicaid HCBS waivers, and their characteristics, on unmet health care needs among children with ASD. METHODS We used data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health with detailed information on the Medicaid HCBS waiver programs of 35 states. Quasi-difference-in-difference-in-differences models were used to determine the effects of waivers and their characteristics on parent report of unmet health care needs of children with ASD compared with children without ASD. RESULTS Greater waiver cost limits per child, estimated costs of services, and enrollment limits were associated with significant decreases in the adjusted rate of unmet health care needs, with considerable variation by household income level. CONCLUSIONS These findings suggest that Medicaid HCBS waivers significantly decrease the unmet need for health care among children with ASD, most substantially among those who would not otherwise qualify for Medicaid. The findings regarding the effects of specific aspects of these waivers can inform the development of insurance policies in other states to address the needs of children with ASD.
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Affiliation(s)
- Douglas L Leslie
- *Penn State College of Medicine, Hershey †RAND Corporation, Pittsburgh ‡Department of Psychiatry and Pediatrics, University of Pennsylvania, Philadelphia, PA
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Koffer Miller KH, Mathew M, Nonnemacher SL, Shea LL. Program experiences of adults with autism, their families, and providers: Findings from a focus group study. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2017; 22:345-356. [PMID: 29152993 DOI: 10.1177/1362361316679000] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A growing number of individuals with autism spectrum disorder are aging into adulthood. In the United States, Medicaid is the primary payer for services for adults with autism spectrum disorder, yet there are few funded programs that provide dedicated supports to this population. This study examined the experiences of adults with autism spectrum disorder in two Medicaid-funded programs in Pennsylvania through focus groups. Researchers conducted 20 focus groups with a total of 36 adults with autism spectrum disorder, 32 family members, 32 direct care staff, and 20 program administrators. Using thematic analysis, we identified three themes: training needs, community engagement and socialization, and employment. There was a need for additional training to meet the varying needs of program participants including co-occurring diagnoses, sexuality, and long-term planning. Adults with autism spectrum disorder prioritized more individualized community activities based on their interests. Finally, barriers to and strategies for successful employment were discussed. It will be crucial for policy makers to utilize the findings to inform program improvement and development based on the experiences of individuals impacted by these services and systems directly. Additionally, researchers should use the findings from this study to design interventions for adults with autism spectrum disorder as it includes their voices.
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Vohra R, Madhavan S, Sambamoorthi U. Comorbidity prevalence, healthcare utilization, and expenditures of Medicaid enrolled adults with autism spectrum disorders. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2016; 21:995-1009. [PMID: 27875247 DOI: 10.1177/1362361316665222] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A retrospective data analysis using 2000-2008 three state Medicaid Analytic eXtract was conducted to examine the prevalence and association of comorbidities (psychiatric and non-psychiatric) with healthcare utilization and expenditures of fee-for-service enrolled adults (22-64 years) with and without autism spectrum disorders (International Classification of Diseases, Ninth Revision-clinical modification code: 299.xx). Autism spectrum disorder cases were 1:3 matched to no autism spectrum disorder controls by age, gender, and race using propensity scores. Study outcomes were all-cause healthcare utilization (outpatient office visits, inpatient hospitalizations, emergency room, and prescription drug use) and associated healthcare expenditures. Bivariate analyses (chi-square tests and t-tests), multinomial logistic regressions (healthcare utilization), and generalized linear models with gamma distribution (expenditures) were used. Adults with autism spectrum disorders (n = 1772) had significantly higher rates of psychiatric comorbidity (81%), epilepsy (22%), infections (22%), skin disorders (21%), and hearing impairments (18%). Adults with autism spectrum disorders had higher mean annual outpatient office visits (32ASD vs 8noASD) and prescription drug use claims (51ASD vs 24noASD) as well as higher mean annual outpatient office visits (US$4375ASD vs US$824noASD), emergency room (US$15,929ASD vs US$2598noASD), prescription drug use (US$6067ASD vs US$3144noASD), and total expenditures (US$13,700ASD vs US$8560noASD). The presence of a psychiatric and a non-psychiatric comorbidity among adults with autism spectrum disorders increased the annual total expenditures by US$4952 and US$5084, respectively.
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Bilaver LA, Cushing LS, Cutler AT. Prevalence and Correlates of Educational Intervention Utilization Among Children with Autism Spectrum Disorder. J Autism Dev Disord 2016; 46:561-71. [PMID: 26391885 DOI: 10.1007/s10803-015-2598-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study examined the prevalence and correlates of educational intervention utilization among U.S. preschool aged children with autism spectrum disorder (ASD) prior to recent policy changes. The analysis was based on a nationally representative longitudinal survey of children receiving special education services during the 2003-2004 school year. All children with parent or teacher identified ASD over a 3-year study period were analyzed. Outcomes included utilization of speech therapy, occupational therapy, behavior therapy, and mental health services by service sector. The analysis revealed low rates of behavioral therapy and mental health services. Parents reported that the overwhelming majority of services were received inside school only. This study identified gaps in the provision of services for young children with ASD.
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Affiliation(s)
- Lucy A Bilaver
- Department of Public Health, School of Nursing and Health Studies, Northern Illinois University, Wirtz Hall Rm. 253, DeKalb, IL, 60115, USA. .,Chapin Hall at the University of Chicago, 1313 E. 60th St., Chicago, IL, 60637, USA.
| | - Lisa S Cushing
- Department of Special Education, College of Education, University of Illinois-Chicago, 1040 W. Harrison St., M/C 147, Chicago, IL, 60660, USA
| | - Ann T Cutler
- Institute on Disability and Human Development, University of Illinois-Chicago, 1640 W. Roosevelt Rd., M/C 727, Chicago, IL, 60608, USA
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