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A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization

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Title: A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization
Language: English
Authors: Robinson, Lee A. (ORCID 0000-0002-3780-7460), Menezes, Michelle, Mullin, Brian, Cook, Benjamin Lê
Source: Journal of Autism and Developmental Disorders. Mar 2020 50(3):1031-1044.
Availability: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 14
Publication Date: 2020
Document Type: Journal Articles
Reports - Research
Descriptors: Autism, Pervasive Developmental Disorders, Children, Costs, Expenditures, Access to Health Care, Public Health, Allied Health Personnel, Diseases, Cost Effectiveness
DOI: 10.1007/s10803-019-04327-z
ISSN: 0162-3257
Abstract: As value-based care continues to expand, more children with autism spectrum disorder (ASD) will be treated by accountable care organizations (ACOs), provider organizations seeking to improve population health while reducing costs. To inform ACO strategies for children with ASD, this study compared health care expenditures of children insured by a Medicaid managed care organization, empaneled to a safety net ACO, with ASD, asthma, and neither diagnosis. Compared to other study groups, children with ASD were more costly, had lower rates of acute care, and had higher rates of "leaked" care provided by home- and community-based mental health agencies outside of the ACO. These findings highlight the need for unique value-based strategies for children with ASD in a public sector ACO.
Abstractor: As Provided
Entry Date: 2020
Accession Number: EJ1243062
Database: ERIC
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  Value: <anid>AN0141662636;aut01mar.20;2020Feb12.03:27;v2.2.500</anid> <title id="AN0141662636-1">A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization </title> <p>As value-based care continues to expand, more children with autism spectrum disorder (ASD) will be treated by accountable care organizations (ACOs), provider organizations seeking to improve population health while reducing costs. To inform ACO strategies for children with ASD, this study compared health care expenditures of children insured by a Medicaid managed care organization, empaneled to a safety net ACO, with ASD, asthma, and neither diagnosis. Compared to other study groups, children with ASD were more costly, had lower rates of acute care, and had higher rates of "leaked" care provided by home- and community-based mental health agencies outside of the ACO. These findings highlight the need for unique value-based strategies for children with ASD in a public sector ACO.</p> <p>Keywords: Autism spectrum disorder; Accountable care organization; Value-based care; Health care expenditures; Health service utilization</p> <hd id="AN0141662636-2">Introduction</hd> <p>Autism spectrum disorder (ASD), often diagnosed in early childhood, is a disorder marked by impairment in social communication and restricted and repetitive behaviors or interests (American Psychiatric Association [<reflink idref="bib2" id="ref1">2</reflink>]). Children with ASD vary widely in their level of functioning and impairment, though most will require some level of therapeutic support in the school, community, or home (Cheak-Zamora and Farmer [<reflink idref="bib11" id="ref2">11</reflink>]; Zablotsky et al. [<reflink idref="bib54" id="ref3">54</reflink>]). Additionally, children with ASD have high rates of medical and psychiatric comorbidities, often requiring specialty care (Schieve et al. [<reflink idref="bib47" id="ref4">47</reflink>]; Simonoff et al. [<reflink idref="bib49" id="ref5">49</reflink>]; Leyfer et al. [<reflink idref="bib30" id="ref6">30</reflink>]). As a result, children with ASD often incur much higher health care costs than children without the diagnosis (Shimabukuro et al. [<reflink idref="bib48" id="ref7">48</reflink>]; Croen et al. [<reflink idref="bib13" id="ref8">13</reflink>]; Mandell et al. [<reflink idref="bib34" id="ref9">34</reflink>]; Lavelle et al. [<reflink idref="bib29" id="ref10">29</reflink>]; Liptak et al. [<reflink idref="bib31" id="ref11">31</reflink>]), and yet also experience high rates of unmet care needs (Farmer et al. [<reflink idref="bib18" id="ref12">18</reflink>]; Cheak-Zamora and Farmer [<reflink idref="bib11" id="ref13">11</reflink>]).</p> <p>As the health care landscape continues to shift towards value-based care, an increasing number of children with ASD are being treated by Accountable Care Organizations (ACOs), provider organizations that are paid for their treatment of patients through value-based payment mechanisms. With more than 1000 ACOs nationwide (Muhlestein et al. [<reflink idref="bib43" id="ref14">43</reflink>]), health care providers are increasingly adopting this new model of care delivery, in which they assume financial responsibility for improving the health and experience of care for their empaneled population of patients (Medicare Payment Advisory Commission [<reflink idref="bib42" id="ref15">42</reflink>]). ACOs achieve financial success by helping patients receive high quality, coordinated, low cost care, and avoiding unnecessary, redundant, or costly interventions. While there is growing evidence that ACOs may help control rising health care costs for adults (Mechanic and Gaus [<reflink idref="bib41" id="ref16">41</reflink>]), there is less certainty about the financial success of empaneling pediatric populations, including children with ASD.</p> <p>For most ACOs, the highest cost pediatric patients will be the growing number of children with chronic medical, psychiatric, and developmental conditions (J.M. Perrin et al. [<reflink idref="bib45" id="ref17">45</reflink>]). This will be particularly true for ACOs caring for large numbers of underserved, Medicaid-insured children, who have significantly higher rates of almost every chronic health condition than their privately insured peers (Bethell et al. [<reflink idref="bib5" id="ref18">5</reflink>]). For ACOs serving these patients, it will be important to identify population-wide strategies to improve quality and reduce costs for children with high rates of comorbid chronic conditions, as well as identify subpopulations of children with specific chronic conditions, like ASD, that may require unique value-based strategies.</p> <p>Among the chronic pediatric health conditions, asthma has perhaps garnered the most focus for quality measurement (Fairbrother and Simpson [<reflink idref="bib16" id="ref19">16</reflink>]; Gliklich et al. [<reflink idref="bib24" id="ref20">24</reflink>]; National Committee for Quality Assurance [<reflink idref="bib44" id="ref21">44</reflink>]), pay-for-performance and alternative payment contracts (Chien et al. [<reflink idref="bib12" id="ref22">12</reflink>]; Gleeson et al. [<reflink idref="bib23" id="ref23">23</reflink>]), and ACO strategies for pediatric populations (Homer and Patel [<reflink idref="bib25" id="ref24">25</reflink>]; Perrin et al. [<reflink idref="bib46" id="ref25">46</reflink>]). Asthma is one of the most prevalent and costly chronic conditions facing pediatric populations (Centers for Disease Control and Prevention [<reflink idref="bib10" id="ref26">10</reflink>]), and in nationally representative surveys, asthma has consistently been one of the most common disorders experienced by children with special health care needs (Brachlow et al. [<reflink idref="bib6" id="ref27">6</reflink>]; Lollar et al. [<reflink idref="bib32" id="ref28">32</reflink>]). In a 2012 study of potentially preventable pediatric hospitalizations, asthma accounted for the highest proportion of hospitalizations among pediatric "ambulatory care-sensitive" (ACS) conditions (Lu and Kuo [<reflink idref="bib33" id="ref29">33</reflink>]). There is evidence that improved attendance at well-child outpatient visits may prevent hospitalizations related to ACS conditions (Tom et al. [<reflink idref="bib52" id="ref30">52</reflink>]), and outpatient care coordination may prevent emergency care visits for children with asthma (Janevic et al. [<reflink idref="bib26" id="ref31">26</reflink>]). Given the wealth of evidence among youth with asthma and the relative dearth of evidence on costs and preventative ambulatory care interventions among children with ASD (Feldman et al. [<reflink idref="bib20" id="ref32">20</reflink>]), a comparison of these populations could assist administrators in identifying the relative benefits of ASD-specific interventions.</p> <p>One particular ACO strategy to consider for children with ASD is the reduction of health care "leakage." "Leakage" is the term for specialty medical care that is provided outside of an ACO's network of providers, for which the ACO is financially responsible (Barnett and McWilliams [<reflink idref="bib4" id="ref33">4</reflink>]). If ACOs can provide the same care themselves, or contract with an agency for a negotiated rate with quality and coordination assurance, they can save money and improve care (Athenahealth, Inc. [<reflink idref="bib3" id="ref34">3</reflink>]). This might be particularly relevant for children with ASD who likely experience significant "leakage" of care in the context of high rates of fragmented specialty, school, community, and home-based care (Zablotsky et al. [<reflink idref="bib54" id="ref35">54</reflink>]; Cheak-Zamora and Farmer [<reflink idref="bib11" id="ref36">11</reflink>]; Schieve et al. [<reflink idref="bib47" id="ref37">47</reflink>]; Simonoff et al. [<reflink idref="bib49" id="ref38">49</reflink>]; Leyfer et al. [<reflink idref="bib30" id="ref39">30</reflink>]). To our knowledge, no one has formally evaluated the issue of care "leakage" for children with ASD empaneled in an ACO.</p> <p>In this context, we sought to inform value-based planning for ACOs serving Medicaid-insured children with ASD by studying patterns of health care utilization and cost within one Medicaid managed care organization (MCO) insuring youth within our ACO. We further aimed to discover if, and how, health care patterns for children with ASD differ from those of children with asthma, and from the rest of the Medicaid MCO pediatric population, to see in what ways children with ASD may warrant unique population health strategies.</p> <hd id="AN0141662636-3">Methods</hd> <p></p> <hd id="AN0141662636-4">Setting</hd> <p>This study was conducted at a community-based, safety net health system in Massachusetts. In 2006, following the passage of a Massachusetts' law reforming healthcare provision and expanding Medicaid eligibility, providers in the health system formed an ACO that contracted with a MCO covering Medicaid beneficiaries. In 2017, this ACO was selected to participate in new MassHealth (Massachusetts Medicaid) ACO contracts that expanded the number of beneficiaries covered by this Medicaid MCO. Starting in 2018, all patients insured by the Medicaid MCO and empaneled to primary care providers within this health system were shifted into value-based contracts with this ACO.</p> <hd id="AN0141662636-5">Inclusion Criteria</hd> <p>After obtaining approval from the Institutional Review Board (IRB), we analyzed insurance claims data from the Medicaid MCO prior to the start of the most recent MassHealth ACO contracts. Specifically, we identified all children (18 years and younger) empaneled to the ACO with at least 1 month of insurance coverage with the Medicaid MCO, and at least one claim during the 2-year time period of July 1st, 2015 through June 30th, 2017. Within this subgroup of youth, we also identified those with a claim affiliated with the diagnosis of asthma and/or ASD (see Appendix, Table 3 for respective ICD codes). Of note, none of the youth in our study had supplemental insurance coverage secondary to their Medicaid MCO insurance.</p> <hd id="AN0141662636-6">Data</hd> <p>Using claims data from the Medicaid MCO, we gathered demographic (age and sex), service utilization, prescription medication data, and diagnostic information on all study participants. We included all claims and their associated health care expenditures paid by the Medicaid MCO during the study period in our analysis, regardless of service location. Expenditure data were separated into prescription costs and service expenditures. Service expenditures were grouped by whether the service was provided by clinicians within the ACO or outside ("leakage"). Service expenditures were categorized by the insurance carrier as being either for physical or mental health care based on diagnosis, billing codes, clinician type, and settings of care as determined by contracts between the insurance carrier and the provider agency. Insurance plan indicators further designated expenditures by location: inpatient (IP), emergency department (ED), outpatient, or ancillary. Type of service and service location were taken from insurance plan indicators on the claims. Outpatient mental health expenditures were further analyzed by Current Procedural Terminology (CPT) code to identify four groups of services: home-/community-based services, clinic-based services, testing services, and other (see Appendix, Table 4 for respective CPT codes).</p> <hd id="AN0141662636-7">Data Analysis</hd> <p>Total member enrollment months for the study period were calculated for each diagnostic patient group. Health care expenditure data were divided by the total member enrollment months for each diagnostic patient group to calculate per-member-per-month (PMPM) expenditure data.</p> <hd id="AN0141662636-8">Statistical Analyses</hd> <p>In unadjusted comparisons, Chi square tests (for dichotomous variables) and paired T-tests (for continuous variables) were conducted to compare demographics, and comorbid mental health and developmental diagnoses, and to compare costs in each clinical setting between each study group. To assess expenditures between those with both ASD and asthma, we additionally compared those with both conditions to those with one or neither of these conditions.</p> <p>We estimated generalized linear regression models (GLM) to compare costs in different clinical settings across study groups, adjusting for age, sex, and comorbid mental health diagnoses. Due to the non-normal and heteroscedastic nature of total medical expense (TME) cost data, we estimated a GLM with a log link and gamma distribution to compare TME for each study group (McCullagh and Nelder [<reflink idref="bib40" id="ref40">40</reflink>]) and to compare "leaked" outpatient mental health costs. The resulting coefficients (β) are log-transformed in the GLM model with the log link. In order to return the coefficient to a more easily interpretable scale, the data are re-transformed by (e<sups>ß</sups> − 1)*100, which calculates the percent difference in expenditures between two categories of a binary independent variable. We estimated an ordinary least squares (OLS) regression to compare the percentage of TME attributed to "leaked" health care costs for each study group to provide the optimal fit of percent data (Manning and Mullahy [<reflink idref="bib39" id="ref41">39</reflink>]). The coefficient in the OLS model can be directly interpreted as the percent difference (β *100) between the two relevant study populations.</p> <hd id="AN0141662636-9">Results</hd> <p>Table 1 presents demographic details and rates of comorbid conditions of the study populations. From a total of 15,243 individuals enrolled for at least 1 month in the Medicaid MCO and empaneled to the health system during the study period, 6781 were children 18 years and younger. Our analysis identified 102 children with a diagnosis of ASD, 1105 children with a diagnosis of asthma, 28 children with both diagnoses, and 5546 children with neither diagnosis. Children with ASD were significantly more likely to be male than children with asthma or neither diagnosis, and children with an asthma diagnosis were slightly older than children with an ASD diagnosis. Children with ASD, compared to children with asthma and neither diagnosis, had significantly higher rates of comorbid intellectual disability, other developmental disorders, attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and other mental health diagnoses. Compared to children without asthma or ASD, children with ASD also had higher rates of comorbid depressive disorders, other mood disorders, and post-traumatic stress disorder. Of note, this is despite the fact that children in our sample with neither a diagnosis of ASD nor asthma were a population with elevated rates of mental health and developmental comorbidity, including 11.25% with other developmental disorders, 10.57% with anxiety disorders, 6.47% with ADHD, 6.02% with depressive disorders, and 3.61% with conduct disorder.</p> <p>Sample demographics and comorbid conditions</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>Total</p></th><th align="left"><p>ASD</p></th><th align="left"><p>Asthma</p></th><th align="left"><p>ASD & asthma</p></th><th align="left"><p>Neither Dx</p></th><th align="left" rowspan="2"><p>p value</p><p>ASD vs. asthma</p></th><th align="left" rowspan="2"><p>p value</p><p>ASD vs. neither Dx</p></th></tr><tr><th align="left"><p>N</p></th><th align="left"><p>6781</p></th><th align="left"><p>102</p></th><th align="left"><p>1105</p></th><th align="left"><p>28</p></th><th align="left"><p>5546</p></th></tr></thead><tbody><tr><td align="left"><p>% male</p></td><td align="left"><p>41%</p></td><td align="left"><p>68%</p></td><td align="left"><p>42%</p></td><td align="left"><p>61%</p></td><td align="left"><p>41%</p></td><td char="." align="char"><p>< 0.0001</p></td><td char="." align="char"><p>< 0.0001</p></td></tr><tr><td align="left"><p>Mean age @ 1st encounter</p></td><td align="left"><p>7.92</p></td><td align="left"><p>6.96</p></td><td align="left"><p>8.89</p></td><td align="left"><p>7.32</p></td><td align="left"><p>7.74</p></td><td char="." align="char"><p>0.0002</p></td><td align="left" /></tr><tr><td align="left" colspan="8"><p>Comorbid developmental diagnoses</p></td></tr><tr><td align="left"><p>Intellectual disability (%)</p></td><td align="left"><p>0.24%</p></td><td align="left"><p>5.88%</p></td><td align="left"><p>0.09%</p></td><td align="left"><p>7.14%</p></td><td align="left"><p>0.13%</p></td><td char="." align="char"><p>< 0.0001</p></td><td char="." align="char"><p>< 0.0001</p></td></tr><tr><td align="left"><p>Other developmental d/o (%)</p></td><td align="left"><p>12.84%</p></td><td align="left"><p>64.71%</p></td><td align="left"><p>15.20%</p></td><td align="left"><p>46.43%</p></td><td align="left"><p>11.25%</p></td><td char="." align="char"><p>< 0.0001</p></td><td char="." align="char"><p>< 0.0001</p></td></tr><tr><td align="left" colspan="8"><p>Comorbid psychiatric diagnoses (those with > 5% prevalence in a population)</p></td></tr><tr><td align="left"><p> ADHD %</p></td><td align="left"><p>7.77%</p></td><td align="left"><p>28.43%</p></td><td align="left"><p>12.13%</p></td><td align="left"><p>17.86%</p></td><td char="." align="left"><p>6.47%</p></td><td char="." align="char"><p>< 0.0001</p></td><td char="." align="char"><p>< 0.0001</p></td></tr><tr><td align="left"><p> Conduct disorder (%)</p></td><td align="left"><p>4.34%</p></td><td align="left"><p>18.63%</p></td><td align="left"><p>6.24%</p></td><td align="left"><p>21.43%</p></td><td align="left"><p>3.61%</p></td><td char="." align="char"><p>< 0.0001</p></td><td char="." align="char"><p>< 0.0001</p></td></tr><tr><td align="left"><p> Anxiety (%)</p></td><td align="left"><p>11.87%</p></td><td align="left"><p>21.57%</p></td><td align="left"><p>16.92%</p></td><td align="left"><p>35.71%</p></td><td align="left"><p>10.57%</p></td><td align="left" /><td char="." align="char"><p>0.0004</p></td></tr><tr><td align="left"><p> Adjustment disorder (%)</p></td><td align="left"><p>4.42%</p></td><td align="left"><p>4.90%</p></td><td align="left"><p>8.24%</p></td><td align="left"><p>3.57%</p></td><td align="left"><p>3.66%</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Depressive disorder (%)</p></td><td align="left"><p>6.87%</p></td><td align="left"><p>10.78%</p></td><td align="left"><p>10.68%</p></td><td align="left"><p>10.71%</p></td><td char="." align="left"><p>6.02%</p></td><td align="left" /><td char="." align="char"><p>0.047</p></td></tr><tr><td align="left"><p> Other mood disorder (%)</p></td><td align="left"><p>2.20%</p></td><td align="left"><p>4.90%</p></td><td align="left"><p>3.53%</p></td><td align="left"><p>10.71%</p></td><td char="." align="left"><p>1.84%</p></td><td align="left" /><td char="." align="char"><p>0.025</p></td></tr><tr><td align="left"><p> Psychotic disorder (%)</p></td><td align="left"><p>1.43%</p></td><td align="left"><p>1.96%</p></td><td align="left"><p>2.26%</p></td><td align="left"><p>7.14%</p></td><td char="." align="left"><p>1.23%</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> PTSD (%)</p></td><td align="left"><p>2.83%</p></td><td align="left"><p>7.84%</p></td><td align="left"><p>5.43%</p></td><td align="left"><p>3.57%</p></td><td align="left"><p>2.22%</p></td><td align="left" /><td char="." align="char"><p>0.0002</p></td></tr><tr><td align="left"><p> Other Mental Health d/o (%)</p></td><td align="left"><p>15.60%</p></td><td align="left"><p>35.29%</p></td><td align="left"><p>23.08%</p></td><td align="left"><p>35.71%</p></td><td char="." align="left"><p>13.65%</p></td><td char="." align="char"><p>0.006</p></td><td char="." align="char"><p>< 0.0001</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>ASD</emph> autism spectrum disorder, <emph>ADHD</emph> attention-deficit/hyperactivity disorder, <emph>PTSD</emph> post-traumatic stress disorder, <emph>d/o</emph> disorder, <emph>Dx</emph> diagnosis</p> <hd id="AN0141662636-10">Health Care Costs (see Appendix, Table 5 for all results)</hd> <p></p> <hd id="AN0141662636-11">Unadjusted Comparisons of Expenditures among Youth with ASD vs. Asthma vs. Neither</hd> <p>Figure 1 outlines the PMPM TME for children with ASD, asthma, and neither diagnosis. For all children in our study, health care services comprised the vast majority of total PMPM health care costs, with prescription drug costs making up a small fraction. Children with ASD and children with asthma both had higher TME than children with neither diagnosis. Children with ASD had 2.5 times higher TME than children with neither an ASD nor asthma diagnosis ($515.72 vs. $208.94). Children with ASD in our study, compared to children with asthma, had 1.7 times higher TME ($515.72 vs. $308.55), 1.1 times higher physical health costs ($239.25 vs. $212.92), and 4.4 times higher mental health care costs ($240.60 vs. $54.50).</p> <p>Graph: Fig. 1 PMPM total medical expenses, and relative proportions of mental health treatment, physical health treatment, and prescription medication expense for each study group</p> <p>Figure 2 displays the differences in PMPM expenditures by health service setting for children with ASD, asthma, and neither diagnosis. Compared to children with asthma, children with ASD in our study had 2.3 times higher outpatient health service costs ($432.63 vs. $187.83), though two times less inpatient and ED costs ($39.35 vs. $80.54). Health service costs for children with ASD were split almost evenly between physical ($236.50) and mental health care ($240.60), and acute care comprised small fractions of each of these cost categories (IP/ED was 11% of physical health service costs and 6% of mental health service costs). Conversely, for children with asthma in our study, most of the health service costs were for physical health care, 31% of which was for acute care in the inpatient or ED setting. Children with neither an ASD nor asthma diagnosis had proportionally similar costs to children with asthma, with markedly less mental health care than physical health care (6.5:1 physical health:mental health care for children with neither diagnosis vs. 3.8:1 for children with asthma), and 30% of physical health care provided in acute care settings.</p> <p>Graph: Fig. 2 PMPM health care expenses by treatment setting for physical health and mental health treatment for each study group</p> <p>Figure 3 highlights the differences in care within and outside (leaked) the ACO by children with ASD, asthma, and neither diagnosis. Children with ASD in our study had 2.3 times the amount of leaked care costs compared to children with asthma, and 3.5 times the amount of leaked care of children with neither ASD nor asthma. Children with ASD had more leaked care than care provided within the health system, in contrast to children with asthma and neither diagnosis who had more care retained within the health system. The vast majority (94%) of leaked care by children with ASD was in the outpatient setting, 80% of which was for outpatient mental health costs. In light of this finding, Fig. 4 displays the breakdown of outpatient mental health care for children with ASD in our study (see Appendix, Table 5 for the breakdown of outpatient mental health costs for all study populations). The largest cost category (85%) within outpatient mental health care for children with ASD in our study was home- and community-based care, all of which was leaked outside of the empaneled health system.</p> <p>Graph: Fig. 3 PMPM health care expenses by treatment setting and study group for physical health and mental health treatment, with comparisons made between expenses within the health system's network of providers and expenses leaked outside of the health system's network of providers</p> <p>Graph: Fig. 4 Distribution of PMPM health care expenses for outpatient mental health treatment for children with autism spectrum disorder</p> <hd id="AN0141662636-12">Unadjusted Comparisons of Expenditures Among Youth with ASD and Asthma and One or Neither Dia...</hd> <p>Children with both ASD and asthma, though a very small proportion of the overall population (0.4%), had higher PMPM costs in almost every single service setting and category than children with one or neither study diagnosis. The pattern of service use and health service costs for children with both ASD and asthma more closely resembled that of children with ASD than children with asthma: more care leaked than retained within the health system, more care for mental health needs than physical health, relatively smaller fraction of physical health care in the acute setting (18% for both diagnoses, 11% for ASD, 31% for asthma), outpatient mental health care was the single largest cost category and the largest contributing category to leaked care (79% for both diagnoses vs. 80% for ASD), and home- and community-based care contributed the most to outpatient mental health care costs (82% for both diagnoses vs. 85% for ASD), all of which was leaked outside of the health system.</p> <hd id="AN0141662636-13">Adjusted Comparisons</hd> <p>In the GLM analysis of TME, when adjusting for age, sex, and comorbid mental health conditions, children with ASD had significantly higher TME than children with neither condition (the regression coefficient corresponds to + 30.0% greater expenditure among the ASD group), and children with Asthma had significantly higher TME than children with neither condition (+ 38.1% greater expenditure) (Table 2). Adjusting for age, sex, and comorbid mental health conditions, children with ASD had significantly higher leaked home-/and community-based outpatient mental health expenditures than children with asthma (p = 0.03; + 99.4%) and children with neither ASD nor asthma (p = 0.002; + 139.0%). Adjusting for age, sex, and comorbid mental health conditions, children with ASD had a significantly higher percentage of their TME leaked outside of the health system than children with asthma (p = 0.02; + 7.2%) and children with neither ASD nor asthma (p = 0.03; + 6.5%).</p> <p>GLM and OLS regression analyses to compare expenses in different clinical settings across study groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="4"><p>Total medical expense (TME)- GLM</p></th><th align="left" colspan="4"><p>Leaked home-/community-based outpatient mental health care- GLM</p></th><th align="left" colspan="4"><p>Leakage as percentage of TME- OLS</p></th></tr><tr><th align="left"><p>Coeff</p></th><th align="left"><p>SE</p></th><th align="left"><p>p value</p></th><th align="left"><p>Conversion to percent difference</p></th><th align="left"><p>Coeff</p></th><th align="left"><p>SE</p></th><th align="left"><p>p value</p></th><th align="left"><p>Conversion to percent difference</p></th><th align="left"><p>Coeff</p></th><th align="left"><p>SE</p></th><th align="left"><p>p value</p></th><th align="left"><p>Conversion to percent difference</p></th></tr></thead><tbody><tr><td align="left"><p>ASD vs. asthma</p></td><td char="." align="char"><p>− 0.0627</p></td><td char="." align="char"><p>0.1232</p></td><td char="." align="char"><p>0.61</p></td><td align="left" /><td char="." align="char"><p>0.6901</p></td><td char="." align="char"><p>0.3114</p></td><td char="." align="char"><p>0.03*</p></td><td align="left"><p>+ 99.4%</p></td><td char="." align="char"><p>0.0716</p></td><td char="." align="char"><p>0.0305</p></td><td char="." align="char"><p>0.02*</p></td><td align="left"><p>+ 7.2%</p></td></tr><tr><td align="left"><p>ASD vs. ASD & asthma</p></td><td char="." align="char"><p>− 0.072</p></td><td char="." align="char"><p>0.2523</p></td><td char="." align="char"><p>0.78</p></td><td align="left" /><td char="." align="char"><p>0.4015</p></td><td char="." align="char"><p>0.5572</p></td><td char="." align="char"><p>0.47</p></td><td align="left" /><td char="." align="char"><p>− 0.0340</p></td><td char="." align="char"><p>0.0624</p></td><td char="." align="char"><p>0.59</p></td><td align="left" /></tr><tr><td align="left"><p>ASD vs. neither</p></td><td char="." align="char"><p>0.2602</p></td><td char="." align="char"><p>0.1196</p></td><td char="." align="char"><p>0.03*</p></td><td align="left"><p>+ 30.0%</p></td><td char="." align="char"><p>0.8712</p></td><td char="." align="char"><p>0.2778</p></td><td char="." align="char"><p>0.002*</p></td><td align="left"><p>+ 139.0%</p></td><td char="." align="char"><p>0.0651</p></td><td char="." align="char"><p>0.0295</p></td><td char="." align="char"><p>0.03*</p></td><td align="left"><p>+ 6.5%</p></td></tr><tr><td align="left"><p>Asthma vs. ASD & asthma</p></td><td char="." align="char"><p>− 0.0093</p></td><td char="." align="char"><p>0.2268</p></td><td char="." align="char"><p>0.97</p></td><td align="left" /><td char="." align="char"><p>− 0.2886</p></td><td char="." align="char"><p>0.5168</p></td><td char="." align="char"><p>0.58</p></td><td align="left" /><td char="." align="char"><p>− 0.1057</p></td><td char="." align="char"><p>0.0561</p></td><td char="." align="char"><p>0.06</p></td><td align="left" /></tr><tr><td align="left"><p>Asthma vs. neither</p></td><td char="." align="char"><p>0.3229</p></td><td char="." align="char"><p>0.0396</p></td><td char="." align="char"><p>< 0.0001*</p></td><td align="left"><p>+ 38.1%</p></td><td char="." align="char"><p>0.1811</p></td><td char="." align="char"><p>0.1867</p></td><td char="." align="char"><p>0.33</p></td><td align="left" /><td char="." align="char"><p>− 0.0065</p></td><td char="." align="char"><p>0.0097</p></td><td char="." align="char"><p>0.50</p></td><td align="left" /></tr></tbody></table> </ephtml> </p> <p>Adjusting for age at first encounter, sex, and all comorbid mental health conditions listed in Appendix Table 3 <emph>Coeff</emph> Coefficient; If coefficient is positive, the first comparison group is larger than second; if coefficient is negative, first comparison group is smaller than second "Conversion to percent difference": For each statistically significant coefficient, we transform the GLM or OLS coefficient to a number that represents the percent difference between the groups for ease of interpretation <emph>ASD</emph> autism spectrum disorder, <emph>GLM</emph> generalized linear model, <emph>Neither</emph> neither ASD or asthma diagnosis, <emph>OLS</emph> ordinary least squares regression model, <emph>SE</emph> standard error, <emph>TME</emph> total medical expense *Significant at p ≤ 0.05</p> <hd id="AN0141662636-14">Discussion</hd> <p>Our study analyzed the patterns of health care costs for children insured by a Medicaid MCO and empaneled to a public, safety net ACO in Massachusetts. Our study is the first, to our knowledge, to compare health care spending of children with ASD to children with asthma in the same health system, and to study patterns of care leakage for children with ASD in a developing ACO. Though the unique nature of our patient population and health system should caution against over-interpretation and generalizability of our results, our findings offer important considerations for ACOs developing value-based care models for children with ASD.</p> <p>Our study demonstrated that children with ASD had markedly higher TME than children without ASD, consistent with other studies of privately-insured (Shimabukuro et al. [<reflink idref="bib48" id="ref42">48</reflink>]; Croen et al. [<reflink idref="bib13" id="ref43">13</reflink>]), Medicaid-insured (Mandell et al. [<reflink idref="bib34" id="ref44">34</reflink>]), and nationally representative (Lavelle et al. [<reflink idref="bib29" id="ref45">29</reflink>]; Liptak et al. [<reflink idref="bib31" id="ref46">31</reflink>]) populations of children. In our sample, children with ASD were also much more costly than children with asthma. Though both children with ASD and with asthma had higher total health care expenditures than children without these conditions, our study highlights the need for potentially different ACO population health strategies.</p> <p>For children with asthma in our study, about one quarter (24%, $64.62) of their total health care service costs was attributed to acute physical health care in the inpatient and ED setting. Several studies have highlighted the potential for outpatient interventions to prevent acute medical care for children with asthma (Flores et al. [<reflink idref="bib22" id="ref47">22</reflink>]; Janevic et al. [<reflink idref="bib26" id="ref48">26</reflink>]; Woods et al. [<reflink idref="bib53" id="ref49">53</reflink>]). In studies by both Woods et al. ([<reflink idref="bib53" id="ref50">53</reflink>]) and Janevic et al. ([<reflink idref="bib26" id="ref51">26</reflink>]), outpatient care coordination, targeting children with prior hospitalizations and ED visits, that incorporated frequent home visits and a focus on addressing social barriers to health, were successful in reducing symptoms and acute care needs for children with asthma. Additionally, Woods et al. demonstrated a return on investment of $1.46 saved in reduced hospitalization and ED costs for every $1 spent on targeted care coordination. For public sector ACOs able to identify children with asthma most at risk for acute care, a home- and community-based program to coordinate outpatient care within the ACO may be the best strategy to improve health outcomes at a lower cost.</p> <p>For children with ASD in our study, only 8% of their total health service costs were provided in the acute care setting, much less than in some other studies (Mandell et al. [<reflink idref="bib34" id="ref52">34</reflink>]). While children with ASD may experience preventable uses of acute care (Deavenport-Saman et al. [<reflink idref="bib14" id="ref53">14</reflink>]; Carbone et al. [<reflink idref="bib9" id="ref54">9</reflink>]), to our knowledge, there have been no studies identifying effective outpatient interventions to prevent acute care. Mandell et al. ([<reflink idref="bib38" id="ref55">38</reflink>]) studied the health care expenditures of Medicaid-insured children with ASD, and while access to respite care, a rare resource, may prevent some hospitalizations, there was no indication that increased use of outpatient services predicted a lower degree of inpatient psychiatric admissions. Further study is required to identify outpatient strategies that can successfully reduce acute care for children with ASD, though if overall proportions of acute care are as low as in our sample, it will be difficult for any intervention to demonstrate a meaningful reduction in acute care spending.</p> <p>In contrast to acute care expenses, children with ASD in our study had 90% ($432.63) of their total health service costs provided in the outpatient setting, the majority of which was leaked care (58%, $252.16) provided outside of the ACO provider network. In fact, children with ASD in our study had nearly as much leaked outpatient care as the total health service costs for children with asthma ($267.42). When controlling for age, sex, and mental health comorbidities, children with ASD had a significantly higher proportion of their TME attributed to leaked care than children with asthma or neither diagnosis. This amount of leaked, fragmented, outpatient care is a potential focus for value-based improvement for children with ASD.</p> <p>In national surveys of parents of children with ASD (Farmer et al. [<reflink idref="bib18" id="ref56">18</reflink>]; Brachlow et al. [<reflink idref="bib6" id="ref57">6</reflink>]; Cheak-Zamora and Farmer [<reflink idref="bib11" id="ref58">11</reflink>]), nearly all children required specialty outpatient services, though most experienced care that was not adequately coordinated or family-centered. In a study by Brachlow et al. ([<reflink idref="bib6" id="ref59">6</reflink>]), these deficits in care quality were unique to children with ASD when compared to children with asthma and children with other special health care needs. This lack of coordinated and family-centered care has been associated with increased unmet care needs for children with ASD (Farmer et al. [<reflink idref="bib18" id="ref60">18</reflink>]; Cheak-Zamora and Farmer [<reflink idref="bib11" id="ref61">11</reflink>]). Additionally, this fragmented care often places considerable time, energy, and financial burden on the caregivers of these children, who are forced to take on the onus of coordinating the care (Kogan et al. [<reflink idref="bib28" id="ref62">28</reflink>]).</p> <p>In our study, 75% ($188.58) of the leaked outpatient care for children with ASD was home- and community-based mental health care. In fact, this care category accounted for the single largest proportion of care for children with ASD in our study, and children with ASD, adjusting for age, sex, and mental health comorbidities, had a significantly higher amount of leaked outpatient home- and community-based mental health care than children with asthma and neither diagnosis. While health systems can reduce leaked care by directing patients to equivalent care provided within the ACO, hospital-based ACOs are unlikely to provide these home- and community-based services, which include Early Intervention (EI), in-home behavioral therapies like Applied Behavior Analysis (ABA), and wrap-around supports for children with serious emotional conditions. Therefore, the largest source of costs for children with ASD in our developing ACO will continue to be provided by outside agencies.</p> <p>ACOs can approach this issue in several ways. ACOs can employ staff to help families of children with ASD coordinate their care. Studies of care coordinators and family navigators for children with ASD have shown improved experience of care and reduced unmet needs (Farmer et al. [<reflink idref="bib17" id="ref63">17</reflink>]) and a reduction in time until diagnosis (Feinberg et al. [<reflink idref="bib19" id="ref64">19</reflink>]). Family navigators, who can go into the home and community to assist families, is particularly appealing for public sector ACOs whose families face considerable social barriers to coordinated care. Not surprising, the work to "integrate a disjointed health care system on behalf of an individual patient," (Broder-Fingert et al. [<reflink idref="bib7" id="ref65">7</reflink>]) is quite laborious, requiring numerous contacts for each patient. As a result, while quality outcomes may improve for children with ASD, and long-term costs may theoretically be reduced, the high short-term costs for employing care coordinators may give pause to ACOs deciding among a variety of value-based strategies.</p> <p>Another approach ACOs can pursue is to develop formal partnerships with home- and community-based agencies serving children with ASD. This fits within the framework of the "medical neighborhood," first proposed in 2008 (Fisher [<reflink idref="bib21" id="ref66">21</reflink>]), described as, "a set of relationships revolving around the patient and his or her (Patient Centered Medical Home), based on that patient's health needs" (Taylor et al. [<reflink idref="bib51" id="ref67">51</reflink>]). In the ACO context, these relationships can be formalized to bring these home- and community-based services within the ACO provider network, and include expectations for coordinated workflows, improved communication, shared accountability, negotiated costs, and quality assurance (Alidina et al. [<reflink idref="bib1" id="ref68">1</reflink>]). This approach is promising for children with ASD where improved communication may quickly lead to improved outcomes (Jimenez et al. [<reflink idref="bib27" id="ref69">27</reflink>]), and improved quality assurance may help children with ASD receive therapeutic supports that adhere more closely to evidence-based standards (Stahmer et al. [<reflink idref="bib50" id="ref70">50</reflink>]; Mandell et al. [<reflink idref="bib36" id="ref71">36</reflink>]).</p> <p>Children in our study with both ASD and asthma, though a very small proportion of the overall population, had TME nearly twice that of children with ASD, and nearly three times that of children with asthma. The cost pattern for this population nearly mirrored that for children with ASD, and so this population, while small may be an appealing pilot population for ASD-specific value-based interventions.</p> <hd id="AN0141662636-15">Limitations</hd> <p>Our study had several important limitations. We studied children insured by one Medicaid MCO, and empaneled to one ACO, and therefore we had a relatively small sample from which to draw statistically significant conclusions. Additionally, as many of the pediatric patients empaneled to our ACO are underserved and of a racial or ethnic minority, which has been associated with delays in autism diagnosis (Mandell et al. [<reflink idref="bib35" id="ref72">35</reflink>]; Mandell et al. [<reflink idref="bib37" id="ref73">37</reflink>]), our sample of children with an ASD diagnosis is likely an underrepresentation of the true ASD prevalence in our population. In this context, we made an intentional decision in our study to maximize sensitivity of diagnostic inclusion by including children with only one claim affiliated with a diagnosis of ASD or asthma. Though requiring two or more claims for ASD or asthma would have increased the positive predictive value of case identification in our study (Burke et al. [<reflink idref="bib8" id="ref74">8</reflink>]), we decided that a more inclusive, public health, population-level approach to diagnostic assignment (Desai et al. [<reflink idref="bib15" id="ref75">15</reflink>]) outweighed the risk of potential diagnostic false positives; this risk, though, is a potential limitation of our study. We did not analyze or adjust for various demographic variables, such as race, ethnicity, language, or household income, though one may assume that children covered by the same Medicaid MCO within a health system with a defined catchment area of exclusively high-density urban cities, may share some degree of demographic similarity.</p> <p>The unique nature of our health system's patient population, service and provider mix, and geopolitical landscape may produce findings with limited generalizability. Specifically, our study was conducted in Massachusetts, and as the result of several acts of legislation [An Act Relative to Insurance Coverage for Autism (ARICA) in 2010 and the Autism Omnibus Law in 2014], all private and public insurers in Massachusetts are required to provide coverage for the diagnosis and treatment of ASD, including in-home therapies like ABA. Additionally, resulting from a class-action lawsuit (Rosie D. vs. Romney in 2006), all Medicaid-insured children in Massachusetts with serious emotional conditions are eligible for home- and community-based mental health supports. Massachusetts also has a Medicaid 1915(C) waiver covering various types of supports and services, including respite, for children with ASD less than 9 years of age. It is in this context that children with ASD in our study incurred such high home- and community-based service costs. Children in other states that do not require insurance coverage for these services may have lower overall and service-specific costs.</p> <p>Lastly, while our study compared the amount and distribution of health care expenditures, we did not assess the quality of these services, the associated health outcomes, nor whether the service use met the needs of each population. Our study is therefore just one part of what should be a multidimensional approach to assessing value in health care for children with ASD.</p> <hd id="AN0141662636-16">Future Directions</hd> <p>Our study predated the official start of the Massachusetts Medicaid ACO Program, which started in 2018, so follow-up studies are needed to fully understand the experience of children with ASD in a public sector ACO. As more health systems across the country pursue accountable care, hopefully more studies will evaluate value-based care for children with ASD from all demographic and geopolitical contexts.</p> <p>Further study is needed to evaluate the following strategies in children with ASD: outpatient interventions that can effectively prevent acute care needs, care coordination and family navigation programs, and formal partnerships with home- and community-based service agencies.</p> <p>It will be particularly important to assess care quality and health outcomes, in parallel to costs, in future studies of children with ASD. This population will likely always be a high cost patient population, and as many studies highlight large unmet needs by families of children with ASD, effective population health approaches may actually increase costs as more children receive needed care. Also, as much of the care for children with ASD is to improve long-term functioning and prevent the need for more intensive services, positive outcomes may manifest outside of the health care system, over extended durations of time. Such outcomes may include improved quality of life, increased independence and productivity, and emotional and financial wellness for these children and their families. Therefore, future studies should ideally include these "non-medical" outcome measures, and follow patients over time, to assess for positive outcomes of ACO value-based strategies.</p> <hd id="AN0141662636-17">Conclusion</hd> <p>Our study compared the health care expenditures of children with ASD, asthma, and neither diagnosis, insured by a Medicaid MCO, in a public-sector health system pursuing a Medicaid ACO partnership. In comparison to children with asthma and neither diagnosis, children with ASD in our study were a markedly high cost patient population and had a unique pattern of health care use. Specifically, children with ASD received the vast majority of their care in the outpatient setting, and had a very high degree of leaked care, primarily from home- and community-based outpatient mental health care. The patterns of health care use by children in our study indicates the potential need for different value-based population health strategies for children with ASD and children with asthma in a public sector ACO.</p> <hd id="AN0141662636-18">Funding</hd> <p>None.</p> <hd id="AN0141662636-19">Acknowledgment</hd> <p>Note that MM was affiliated with Cambridge Health Alliance at the time of the data collection.</p> <hd id="AN0141662636-20">Author Contributions</hd> <p>LR conceived of the study, participated in its design and coordination, interpreted the data, drafted most of the manuscript, and participated in the critical revision of the manuscript. MM was involved in the interpretation of data, drafting of the manuscript and the critical revision of the manuscript. BM was involved in the interpretation of data, performed the statistical analysis, participated in drafting of the manuscript and the critical revision of the manuscript. BC was involved in the conception, design, and coordination of the study, interpretation of the data, drafting the manuscript and the critical revision of the manuscript. All authors read and approved the final manuscript.</p> <hd id="AN0141662636-21">Compliance with Ethical Standards</hd> <p></p> <hd id="AN0141662636-22">Conflict of interest</hd> <p>BM has stock equity ownership in the following companies: Proctor & Gamble, Shire PLC, Baxter International, Abbott Labs, AbbVie Inc, Bristol Meyers, and other non-health care equity holdings. The other authors declare that they have no potential conflicts of interest.</p> <hd id="AN0141662636-23">Ethical Approval</hd> <p>This study was approved by the Institutional Review Board of the Cambridge Health Alliance.</p> <hd id="AN0141662636-24">Appendix</hd> <p>See Tables 3, 4 and 5.</p> <p>Diagnoses and associated ICD codes</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Diagnosis</p></th><th align="left"><p>ICD9 codes</p></th><th align="left"><p>ICD10 codes</p></th></tr></thead><tbody><tr><td align="left"><p>ASD</p></td><td align="left"><p>299.0, 299.8, 299.9</p></td><td align="left"><p>F84.0, F84.1, F84.5, F84.8, F84.9</p></td></tr><tr><td align="left"><p>Asthma</p></td><td align="left"><p>493</p></td><td align="left"><p>J45</p></td></tr><tr><td align="left"><p>Intellectual disabilities</p></td><td align="left"><p>317–319</p></td><td align="left"><p>F70–F79</p></td></tr><tr><td align="left"><p>ADHD</p></td><td align="left"><p>314</p></td><td align="left"><p>F90</p></td></tr><tr><td align="left"><p>Other developmental disorders</p></td><td align="left"><p>315 and 299.1</p></td><td align="left"><p>F80, F81, F82, F84.2, F84.3, F88, F89</p></td></tr><tr><td align="left"><p>Depressive disorders</p></td><td align="left"><p>296.2, 296.3, 300.4, 311</p></td><td align="left"><p>F32, F33, F34.1</p></td></tr><tr><td align="left"><p>Psychotic disorders</p></td><td align="left"><p>295, 297, 298</p></td><td align="left"><p>F20–F29</p></td></tr><tr><td align="left"><p>Bipolar disorders</p></td><td align="left"><p>296.0, 296.1, 296.4, 296.5, 296.6, 296.7, 296.8</p></td><td align="left"><p>F30, F31</p></td></tr><tr><td align="left"><p>Other mood disorders</p></td><td align="left"><p>296.9</p></td><td align="left"><p>F34.0, F34.8, F34.9, F39</p></td></tr><tr><td align="left"><p>Anxiety disorders</p></td><td align="left"><p>300.0, 300.2, 313.23, 30921</p></td><td align="left"><p>F40, F41, F93.0, F94.0</p></td></tr><tr><td align="left"><p>OCD</p></td><td align="left"><p>300.3</p></td><td align="left"><p>F42</p></td></tr><tr><td align="left"><p>Substance use disorders</p></td><td align="left"><p>291, 292, 303, 304, 305</p></td><td align="left"><p>F10–F19</p></td></tr><tr><td align="left"><p>Adjustment disorders</p></td><td align="left"><p>309.0, 309.1, 309.2, 309.20, 309.22, 309.23, 309.24, 309.25, 309.26, 309.27, 309.28, 309.29, 309.3, 309.4, 309.82, 309.83, 309.84, 309.85, 309.86, 309.87, 309.88, 309.89, 309.9</p></td><td align="left"><p>F43.2</p></td></tr><tr><td align="left"><p>Conduct disorders</p></td><td align="left"><p>312</p></td><td align="left"><p>F91.0, F91.1, F91.2, F91.8, F91.9</p></td></tr><tr><td align="left"><p>ODD</p></td><td align="left"><p>313.81</p></td><td align="left"><p>F91.3</p></td></tr><tr><td align="left"><p>Eating disorders</p></td><td align="left"><p>307.1, 307.5</p></td><td align="left"><p>F50</p></td></tr><tr><td align="left"><p>Sleep disorders</p></td><td align="left"><p>307.4</p></td><td align="left"><p>F51</p></td></tr><tr><td align="left"><p>PTSD</p></td><td align="left"><p>309.81</p></td><td align="left"><p>F43.1</p></td></tr><tr><td align="left"><p>Stress reaction</p></td><td align="left"><p>308</p></td><td align="left"><p>F43.0, F43.8, F43.9</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>ICD</emph> international classification of diseases, <emph>ASD</emph> autism spectrum disorder, <emph>ADHD</emph> attention-deficit/hyperactivity disorder, <emph>OCD</emph> obsessive–compulsive disorder, <emph>ODD</emph> oppositional-defiant disorder, <emph>PTSD</emph> post-traumatic stress disorder</p> <p>Visit-types and associated CPT codes</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Visit type</p></th><th align="left"><p>CPT Codes</p></th></tr></thead><tbody><tr><td align="left"><p>Clinic-based services</p></td><td align="left"><p>90791, 90792, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90870</p></td></tr><tr><td align="left"><p>Testing services</p></td><td align="left"><p>96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120</p></td></tr><tr><td align="left"><p>Home- & community-based services</p></td><td align="left"><p>H0031, H0032, H0038, H2011, H2012, H2014, H2015, H2019, S9484, S9485, T1015, T1017, T1023, T1024, T1027, 96153</p></td></tr><tr><td align="left"><p>Other</p></td><td align="left"><p>All remaining CPT codes classified as outpatient mental health by the insurance carrier. The three such CPT codes with the largest associated expenditures include:</p><p>90882: Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions</p><p>90887: Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient</p><p>99219: Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 min are spent at the bedside and on the patient's hospital floor or unit.</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>CPT</emph> current procedural terminology</p> <p>PMPM health care expenses</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>Autism</p></th><th align="left"><p>Asthma</p></th><th align="left"><p>Autism & asthma</p></th><th align="left"><p>Neither diagnosis</p></th><th align="left"><p>p value</p><p>ASD vs. asthma</p></th><th align="left"><p>p value</p><p>ASD vs. neither diagnosis</p></th><th align="left"><p>p value</p><p>ASD & asthma vs. ASD</p></th></tr></thead><tbody><tr><td align="left"><p>Total health care costs</p></td><td align="left"><p>$515.72</p></td><td align="left"><p>$308.55</p></td><td align="left"><p>$823.82</p></td><td align="left"><p>$208.94</p></td><td align="left" /><td align="left"><p>0.0538</p></td><td align="left" /></tr><tr><td align="left"><p> Total health care service costs</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Within</p></td><td align="left"><p>$210.50</p></td><td align="left"><p>$149.00</p></td><td align="left"><p>$317.25</p></td><td align="left"><p>$117.08</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Leakage</p></td><td align="left"><p>$269.35</p></td><td align="left"><p>$118.42</p></td><td align="left"><p>$430.56</p></td><td align="left"><p>$77.80</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Total</p></td><td align="left"><p>$479.85</p></td><td align="left"><p>$267.42</p></td><td align="left"><p>$747.81</p></td><td align="left"><p>$194.88</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Rx</p></td><td align="left"><p>$35.87</p></td><td align="left"><p>$41.13</p></td><td align="left"><p>$76.01</p></td><td align="left"><p>$14.06</p></td><td align="left" /><td align="left"><p>0.5452</p></td><td align="left"><p>0.042</p></td></tr><tr><td align="left"><p> Physical health</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Total</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$177.78</p></td><td align="left"><p>$139.02</p></td><td align="left"><p>$170.42</p></td><td align="left"><p>$112.04</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$61.47</p></td><td align="left"><p>$73.90</p></td><td align="left"><p>$87.91</p></td><td align="left"><p>$57.18</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$239.25</p></td><td align="left"><p>$212.92</p></td><td align="left"><p>$258.33</p></td><td align="left"><p>$169.22</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Inpatient</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$5.59</p></td><td align="left"><p>$2.48</p></td><td align="left"><p>$0</p></td><td align="left"><p>$8.49</p></td><td align="left" /><td align="left"><p>0.461</p></td><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$2.62</p></td><td align="left"><p>$34.67</p></td><td align="left"><p>$7.32</p></td><td align="left"><p>$23.79</p></td><td align="left" /><td align="left"><p>0.6524</p></td><td align="left" /></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$8.21</p></td><td align="left"><p>$37.15</p></td><td align="left"><p>$7.32</p></td><td align="left"><p>$32.28</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  ER</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$12.21</p></td><td align="left"><p>$19.06</p></td><td align="left"><p>$28.51</p></td><td align="left"><p>$12.00</p></td><td align="left" /><td align="left" /><td align="left"><p>0.023</p></td></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$5.30</p></td><td align="left"><p>$8.41</p></td><td align="left"><p>$11.46</p></td><td align="left"><p>$5.40</p></td><td align="left" /><td align="left" /><td align="left"><p>0.039</p></td></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$17.51</p></td><td align="left"><p>$27.47</p></td><td align="left"><p>$39.97</p></td><td align="left"><p>$17.40</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Outpatient</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$159.98</p></td><td align="left"><p>$117.48</p></td><td align="left"><p>$141.91</p></td><td align="left"><p>$91.55</p></td><td align="left"><p>0.011</p></td><td align="left"><p>0.0002</p></td><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$50.80</p></td><td align="left"><p>$26.65</p></td><td align="left"><p>$62.33</p></td><td align="left"><p>$26.40</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$210.78</p></td><td align="left"><p>$144.13</p></td><td align="left"><p>$204.24</p></td><td align="left"><p>$117.95</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Ancillary</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>–</p></td><td align="left"><p>–</p></td><td align="left"><p>–</p></td><td align="left"><p>–</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$2.75</p></td><td align="left"><p>$4.17</p></td><td align="left"><p>$6.80</p></td><td align="left"><p>$1.59</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Mental health</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Total</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$32.72</p></td><td align="left"><p>$9.98</p></td><td align="left"><p>$146.83</p></td><td align="left"><p>$5.04</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$207.88</p></td><td align="left"><p>$44.52</p></td><td align="left"><p>$342.65</p></td><td align="left"><p>$20.62</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$240.60</p></td><td align="left"><p>$54.50</p></td><td align="left"><p>$489.48</p></td><td align="left"><p>$25.66</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Inpatient</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$12.23</p></td><td align="left"><p>$7.11</p></td><td align="left"><p>$123.98</p></td><td align="left"><p>$3.00</p></td><td align="left" /><td align="left" /><td align="left"><p>0.049</p></td></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$6.52</p></td><td align="left"><p>$3.33</p></td><td align="left"><p>–</p></td><td align="left"><p>$2.39</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$13.63</p></td><td align="left"><p>$15.56</p></td><td align="left"><p>$123.98</p></td><td align="left"><p>$5.39</p></td><td align="left" /><td align="left" /><td align="left"><p>Within vs. leakage 0.0297</p></td></tr><tr><td align="left"><p>  ER</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>–</p></td><td align="left"><p>–</p></td><td align="left"><p>–</p></td><td align="left"><p>–</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>–</p></td><td align="left"><p>$0.36</p></td><td align="left"><p>$3.79</p></td><td align="left"><p>$0.25</p></td><td align="left" /><td align="left" /><td align="left"><p>0.022</p></td></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>–</p></td><td align="left"><p>$0.36</p></td><td align="left"><p>$3.79</p></td><td align="left"><p>$0.25</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Outpatient</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$20.49</p></td><td align="left"><p>$2.87</p></td><td align="left"><p>$22.85</p></td><td align="left"><p>$2.04</p></td><td align="left"><p>< 0.0001</p></td><td align="left"><p>< 0.0001</p></td><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$201.36</p></td><td align="left"><p>$40.83</p></td><td align="left"><p>$338.86</p></td><td align="left"><p>$17.98</p></td><td align="left"><p>< 0.0001</p></td><td align="left"><p>< 0.0001</p></td><td align="left" /></tr><tr><td align="left"><p>   Total</p></td><td align="left"><p>$221.85</p></td><td align="left"><p>$43.70</p></td><td align="left"><p>$361.71</p></td><td align="left"><p>$20.02</p></td><td align="left"><p>Within vs. leakage < 0.0001</p></td><td align="left"><p>Within vs. leakage < 0.0001</p></td><td align="left" /></tr><tr><td align="left"><p>  Clinic-based</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$18.40</p></td><td align="left"><p>$2.79</p></td><td align="left"><p>$21.12</p></td><td align="left"><p>$2.00</p></td><td align="left"><p>< 0.0001</p></td><td align="left"><p>< 0.0001</p></td><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$9.52</p></td><td align="left"><p>$7.63</p></td><td align="left"><p>$23.05</p></td><td align="left"><p>$3.10</p></td><td align="left" /><td align="left"><p>0.0075</p></td><td align="left" /></tr><tr><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>Within vs. leakage 0.0008</p></td><td align="left"><p>Within vs. leakage < 0.0001</p></td><td align="left" /></tr><tr><td align="left"><p>  Testing</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$1.75</p></td><td align="left"><p>–</p></td><td align="left"><p>$1.53</p></td><td align="left"><p>$0.03</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$1.51</p></td><td align="left"><p>$0.25</p></td><td align="left"><p>$3.33</p></td><td align="left"><p>$0.11</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>  Home-/community-based</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$188.58</p></td><td align="left"><p>$30.00</p></td><td align="left"><p>$297.37</p></td><td align="left"><p>$13.66</p></td><td align="left"><p>< 0.0001</p></td><td align="left"><p>< 0.0001</p></td><td align="left" /></tr><tr><td align="left"><p>  Other</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Within</p></td><td align="left"><p>$0.34</p></td><td align="left"><p>$0.09</p></td><td align="left"><p>$0.20</p></td><td align="left"><p>$0.02</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>   Leakage</p></td><td align="left"><p>$1.76</p></td><td align="left"><p>$2.95</p></td><td align="left"><p>$15.12</p></td><td align="left"><p>$1.11</p></td><td align="left" /><td align="left" /><td align="left"><p>0.096</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>PMPM</emph> per-member per-month, <emph>Rx</emph> prescription medications, <emph>ER</emph> emergency department</p> <p>Within: Within the empaneled health system, Leakage: Outside the empaneled health system</p> <hd id="AN0141662636-25">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional 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  Data: A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization
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  Data: <searchLink fieldCode="AR" term="%22Robinson%2C+Lee+A%2E%22">Robinson, Lee A.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-3780-7460">0000-0002-3780-7460</externalLink>)<br /><searchLink fieldCode="AR" term="%22Menezes%2C+Michelle%22">Menezes, Michelle</searchLink><br /><searchLink fieldCode="AR" term="%22Mullin%2C+Brian%22">Mullin, Brian</searchLink><br /><searchLink fieldCode="AR" term="%22Cook%2C+Benjamin+Lê%22">Cook, Benjamin Lê</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. Mar 2020 50(3):1031-1044.
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  Data: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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– Name: Pages
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  Data: 14
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  Data: 2020
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Costs%22">Costs</searchLink><br /><searchLink fieldCode="DE" term="%22Expenditures%22">Expenditures</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Health+Care%22">Access to Health Care</searchLink><br /><searchLink fieldCode="DE" term="%22Public+Health%22">Public Health</searchLink><br /><searchLink fieldCode="DE" term="%22Allied+Health+Personnel%22">Allied Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Diseases%22">Diseases</searchLink><br /><searchLink fieldCode="DE" term="%22Cost+Effectiveness%22">Cost Effectiveness</searchLink>
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  Data: 10.1007/s10803-019-04327-z
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  Data: 0162-3257
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: As value-based care continues to expand, more children with autism spectrum disorder (ASD) will be treated by accountable care organizations (ACOs), provider organizations seeking to improve population health while reducing costs. To inform ACO strategies for children with ASD, this study compared health care expenditures of children insured by a Medicaid managed care organization, empaneled to a safety net ACO, with ASD, asthma, and neither diagnosis. Compared to other study groups, children with ASD were more costly, had lower rates of acute care, and had higher rates of "leaked" care provided by home- and community-based mental health agencies outside of the ACO. These findings highlight the need for unique value-based strategies for children with ASD in a public sector ACO.
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      – SubjectFull: Autism
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      – SubjectFull: Pervasive Developmental Disorders
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      – SubjectFull: Children
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      – TitleFull: A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization
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