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Grosse SD, Nichols P, Nyarko K, Maenner M, Danielson ML, Shea L. Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses. J Autism Dev Disord 2022; 52:4150-4163. [PMID: 34581918 PMCID: PMC9077262 DOI: 10.1007/s10803-021-05269-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 12/19/2022]
Abstract
Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA.
| | - Phyllis Nichols
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Kwame Nyarko
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Matthew Maenner
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Melissa L Danielson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop S106-4, Atlanta, GA, 30341, USA
| | - Lindsay Shea
- Policy and Analytics Center, A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
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Sridhar A, Kuhn J, Faja S, Sabatos-DeVito M, Nikolaeva JI, Dawson G, Nelson CA, Webb SJ, Bernier R, Jeste S, Chawarska K, Sugar CA, Shic F, Naples A, Dziura J, McPartland JC. Patterns of Intervention Utilization Among School-Aged Children with Autism Spectrum Disorder: Findings from a Multi-Site Research Consortium. RESEARCH IN AUTISM SPECTRUM DISORDERS 2022; 94. [PMID: 35444715 PMCID: PMC9015686 DOI: 10.1016/j.rasd.2022.101950] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
When designing and interpreting results from clinical trials evaluating treatments for children on the autism spectrum, a complicating factor is that most children receive a range of concurrent treatments. Thus, it is important to better understand the types and hours of interventions that participants typically receive as part of standard of care, as well as to understand the child, family, and geographic factors that are associated with different patterns of service utilization. In this multi-site study, we interviewed 280 caregivers of 6-to-11-year-old school-aged children on the autism spectrum about the types and amounts of interventions their children received in the prior 6 weeks. Reported interventions were coded as "evidence-based practice" or "other interventions," reflecting the level of empirical support. Results indicated that children received a variety of interventions with varying levels of empirical evidence and a wide range of hours (0 to 79.3 hours/week). Children with higher autism symptom levels, living in particular states, and who identified as non-Hispanic received more evidence-based intervention hours. Higher parental education level related to more hours of other interventions. Children who were younger, had lower cognitive ability, and with higher autism symptom levels received a greater variety of interventions overall. Thus, based on our findings, it would seem prudent when designing clinical trials to take into consideration a variety of factors including autism symptom levels, age, cognitive ability, ethnicity, parent education and geographic location. Future research should continue to investigate the ethnic, racial, and socioeconomic influences on school-aged intervention services.
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Affiliation(s)
- Aksheya Sridhar
- Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | | | - Susan Faja
- Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - Maura Sabatos-DeVito
- Department of Psychiatry and Behavioral Sciences, Duke Center for Autism and Brain Development, Duke University, Durham, NC, USA
| | | | - Geraldine Dawson
- Department of Psychiatry and Behavioral Sciences, Duke Center for Autism and Brain Development, Duke University, Durham, NC, USA
| | - Charles A Nelson
- Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - Sara J Webb
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA, USA
| | - Raphael Bernier
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA, USA
| | | | | | | | - Frederick Shic
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA, USA
| | | | - James Dziura
- Yale Center for Analytical Sciences, New Haven, CT USA
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Zhang W, Thompson KL, Watson LR, LaForett DR. Health Care Utilization for Privately and Publicly Insured Children During Autism Insurance Reform. J Autism Dev Disord 2021; 52:5042-5049. [PMID: 34816340 DOI: 10.1007/s10803-021-05370-5] [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: 11/10/2021] [Indexed: 11/29/2022]
Abstract
We examined the effects of insurance type on health service utilization among children with autism spectrum disorder (ASD) following autism insurance reform by analyzing the most recent data from the 2019 National Survey of Children's Health. Families with private insurance were less likely to report that their health insurance covered needed services compared to families with public insurance. Privately versus publicly insured children were not significantly different in receiving behavioral or medication treatment, or in parental frustration in efforts to obtain services. However, parents' frustration escalated with increased ASD severity. Findings from this study suggest the need for continuing to improve implementation of health insurance reform legislation and providing adequate ASD-related services for children with private insurance.
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Affiliation(s)
- Wanqing Zhang
- Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, 321 S. Columbia Street, Chapel Hill, NC, 27599-7122, USA.
| | - Kelsey L Thompson
- Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, 321 S. Columbia Street, Chapel Hill, NC, 27599-7122, USA
| | - Linda R Watson
- Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, 321 S. Columbia Street, Chapel Hill, NC, 27599-7122, USA
| | - Doré R LaForett
- Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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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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Grosse SD, Ji X, Nichols P, Zuvekas SH, Rice CE, Yeargin-Allsopp M. Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017. Psychiatr Serv 2021; 72:16-22. [PMID: 33076792 PMCID: PMC7879423 DOI: 10.1176/appi.ps.202000099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Rapid increases in the prevalence of autism spectrum disorder (ASD) and increased access to intensive behavioral interventions have likely increased health care spending. This study estimated recent changes in spending among privately insured children with and without current ASD. METHODS A repeated cross-sections analysis of 2011-2017 claims data from large-employer-sponsored health plans assessed changes in annual expenditures by service type for children ages 3-7 enrolled for ≥1 year and with two or more claims with ASD billing codes within a calendar year and for all other children. RESULTS Mean spending per child with a current-year ASD diagnosis increased by 51% in 2017 U.S. dollars, from roughly $13,000 in 2011 to $20,000 in 2017. Among children who did not meet the current-year ASD case definition, per-child spending increased by 8%. Spending on children with ASD accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending per child with ASD increased by 376%, from $1,746 in 2011 to $8,317 in 2017; spending on all other services increased by 2%. Their share of behavioral intervention-related spending increased from 13.2% in 2011 to 41.7% in 2017. In 2011, 2.5% of children with current-year ASD diagnoses incurred ≥$20,000 in outpatient behavioral intervention-related spending, which increased to 14.4% in 2017. CONCLUSIONS During 2011-2017, spending increased six times as much for privately insured children ages 3-7 with current-year ASD as for children without ASD, largely from increased behavioral intervention-related spending. One in seven children received at least $20,000 in services in 2017.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta (Grosse, Nichols, Yeargin-Allsopp); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (Ji); Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland (Zuvekas); Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Rice). This work was performed when Dr. Ji was a Prevention Effectiveness Fellow at the CDC
| | - Xu Ji
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta (Grosse, Nichols, Yeargin-Allsopp); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (Ji); Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland (Zuvekas); Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Rice). This work was performed when Dr. Ji was a Prevention Effectiveness Fellow at the CDC
| | - Phyllis Nichols
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta (Grosse, Nichols, Yeargin-Allsopp); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (Ji); Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland (Zuvekas); Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Rice). This work was performed when Dr. Ji was a Prevention Effectiveness Fellow at the CDC
| | - Samuel H Zuvekas
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta (Grosse, Nichols, Yeargin-Allsopp); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (Ji); Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland (Zuvekas); Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Rice). This work was performed when Dr. Ji was a Prevention Effectiveness Fellow at the CDC
| | - Catherine E Rice
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta (Grosse, Nichols, Yeargin-Allsopp); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (Ji); Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland (Zuvekas); Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Rice). This work was performed when Dr. Ji was a Prevention Effectiveness Fellow at the CDC
| | - Marshalyn Yeargin-Allsopp
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta (Grosse, Nichols, Yeargin-Allsopp); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (Ji); Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland (Zuvekas); Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Rice). This work was performed when Dr. Ji was a Prevention Effectiveness Fellow at the CDC
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McBain RK, Cantor JH, Kofner A, Stein BD, Yu H. State Insurance Mandates and the Workforce for Children With Autism. Pediatrics 2020; 146:peds.2020-0836. [PMID: 32900876 PMCID: PMC7546088 DOI: 10.1542/peds.2020-0836] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND State mandates have required insurance companies to provide coverage for autism-related child health care services; however, it has not been determined if insurance mandates have improved the supply of child health care providers. We investigate the effect of state insurance mandates on the supply of child psychiatrists, pediatricians, and board-certified behavioral analysts (BCBAs). METHODS We used data from the National Conference of State Legislatures and Health Resources and Services Administration's Area Health Resource Files to examine child psychiatrists, pediatricians, and BCBAs in all 50 states from 2003 to 2017. Fixed-effects regression models compared change in workforce density before versus one year after mandate implementation and the effect of mandate generosity across 44 US states implementing mandates between 2003 and 2017. RESULTS From 2003 to 2017, child psychiatrists increased from 7.40 to 10.03 per 100 000 children, pediatricians from 62.35 to 68.86, and BCBAs from 1.34 to 29.88. Mandate introduction was associated with an additional increase of 0.77 BCBAs per 100 000 children (95% confidence interval [CI]: 0.18 to 1.42) one year after mandate enactment. Mandate introduction was also associated with a more modest increase among child psychiatrists (95% CI: 0.10 to 0.91) and was not associated with the prevalence of pediatricians (95% CI: -0.76 to 1.13). We also found evidence that more generous mandate benefits were associated with larger effects on workforce supply. CONCLUSIONS State insurance mandates were associated with an ∼16% increase in BCBAs from 2003 to 2017, but the association with child psychiatrists was smaller and nonsignificant among pediatricians. In these findings, it is suggested that policies are needed that specifically address workforce constraints in the provision of services for children with autism spectrum disorder.
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Affiliation(s)
| | | | | | | | - Hao Yu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
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Stadnick NA, Lau AS, Dickson KS, Pesanti K, Innes-Gomberg D, Brookman-Frazee L. Service use by youth with autism within a system-driven implementation of evidence-based practices in children's mental health services. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2020; 24:2094-2103. [PMID: 32686469 DOI: 10.1177/1362361320934230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Public mental health systems play an important role in caring for youth with autism spectrum disorder. Like other dually diagnosed populations, youth with autism spectrum disorder may receive services in the context of evidence-based practice implementation efforts within public mental health systems. Little is known about service use patterns within the context of system-driven implementations efforts for this population. This case-control study examined mental health service patterns of 2537 youth with autism spectrum disorder compared to 2537 matched peers receiving care in the Los Angeles County Department of Mental Health, the largest public mental health department in the United States, within the context of a system-driven implementation of multiple evidence-based practices. Although not the primary target of this implementation effort, youth with autism spectrum disorder were served when they met criteria for the services based on their presenting mental health symptoms. Comparative analyses using administrative claims data were conducted to examine differences in mental health utilization patterns and clinical characteristics. Findings revealed significant differences in the volume and duration of mental health services as well as differences in the service type and evidence-based practice delivered between youth with and without autism spectrum disorder. Results provide direction targeting implementation efforts for youth with autism spectrum disorder within a public mental health system care reform.
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Affiliation(s)
- Nicole A Stadnick
- University of California, San Diego, USA.,Dissemination and Implementation Science Center, University of California San Diego, USA.,Child and Adolescent Services Research Center, USA
| | - Anna S Lau
- University of California Los Angeles, USA
| | - Kelsey S Dickson
- Child and Adolescent Services Research Center, USA.,San Diego State University, USA
| | - Keri Pesanti
- Los Angeles County Department of Mental Health, USA
| | | | - Lauren Brookman-Frazee
- University of California, San Diego, USA.,Dissemination and Implementation Science Center, University of California San Diego, USA.,Child and Adolescent Services Research Center, USA.,Autism Discovery Institute, Rady Children's Hospital San Diego, USA
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McBain RK, Kareddy V, Cantor JH, Stein BD, Yu H. Systematic Review: United States Workforce for Autism-Related Child Healthcare Services. J Am Acad Child Adolesc Psychiatry 2020; 59:113-139. [PMID: 31150751 PMCID: PMC6883168 DOI: 10.1016/j.jaac.2019.04.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/11/2019] [Accepted: 05/21/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE A diversity of health professional disciplines provide services for children with autism spectrum disorder (ASD) in the United States. We conducted a systematic review examining the availability, distribution, and competencies of the US workforce for autism-related child health care services, and assess studies' strength of evidence. METHOD We searched PubMed, PsychINFO, Embase, and Google Scholar from 2008 to 2018 for relevant US-based studies. Two investigators independently screened and evaluated studies against a set of prespecified inclusion criteria and evaluated strength of evidence (SOE) using a framework designed to integrate a mixed-methods research. RESULTS Of 754 records identified, 33 studies (24 quantitative, 6 qualitative, and 3 mixed-methods) were included. Strength of evidence associated was low-to-moderate, with only 8 studies (24%) satisfying criteria for strong SOE. Geographies and provider cadres varied considerably. The most common specialties studied were pediatricians (n = 13), occupational therapists (n = 12), speech therapists (n = 11), physical therapists (n = 10), and child psychiatrists (n = 8). Topical areas included the following: provider availability by service area and care delivery model; qualitative assessments of provider availability and competency; role of insurance mandates in increasing access to providers: and disparities in access. Across provider categories, we found that workforce availability for autism-related services was limited in terms of overall numbers, time available, and knowledgeability. The greatest unmet need was observed among minorities and in rural settings. Most studies were short term, were limited in scope, and used convenience samples. CONCLUSION There is limited evidence to characterize the availability and distribution of the US workforce for autism-related child health care services. Existing evidence to date indicates significantly restricted availability.
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Affiliation(s)
| | | | | | | | - Hao Yu
- RAND Corporation, Pittsburgh, PA
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