Prescription Drug Use and Cost Trends Among Medicaid-Enrolled Children with Disruptive Behavioral Disorders
Disruptive behavior disorders (DBDs) are the most common mental health conditions in children. These conditions profoundly affect healthcare utilization and costs. Service use, costs, and diagnostic trends among pediatric Medicaid beneficiaries provide information regarding healthcare quality and potential for smarter spending. Using nationwide Medicaid administrative data, this study investigates diagnoses, prescription drug fills, and payments in 49 states and D.C. from 2006 to 2009 in Medicaid beneficiaries age 20 and under. Psychotherapeutic drug prescriptions and payments were calculated as a proportion of prescription totals. Results were considered by age, gender, race, and state. The results show a trend of increasing DBD diagnosis. Among prescription claims for children with diagnosed DBD, psychotherapeutic drug claims represented 30–40% of prescription claims but over half of prescription costs. This study indicates increasing clinical and financial needs for Medicaid-enrolled children with DBDs. Medicaid could potentially foster reforms in pediatric DBD treatments, particularly regarding medication use.
The authors acknowledge our CMS colleagues William D. Clark, Sophia Chan, David Bott, Renee Mentnech, John O’Brien, John Coster, and Renee Hilliard for their input and review.
The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
- 1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Arlington, VA: American Psychiatric Association, 1994.Google Scholar
- 2.U.S. Food & Drug Administration. Pediatric Expertise for Advisory Panels: Guidance for Industry and FDA Staff. U.S. Department of Health & Human Services. Available online at https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm082188.pdf. Accessed on February 10, 2017.
- 3.Families and Youth. Conduct Disorder. American Academy of Child & Adolescent Psychiatry. Available online at https://www.aacap.org/aacap/Families_and_Youth/Facts_for_Families/FFF-Guide/Conduct-Disorder-033.aspx. Accessed on February 10, 2017.
- 4.Gold J. CDC Takes A Closer Look At Kids’ Mental Health. Kaiser Health News. Available online at https://khn.org/news/cdc-takes-a-closer-look-at-kids-mental-health/. Accessed on February 10, 2017.
- 5.Cohen-Salmon C. Collective Expert Report: Conduct Disorder in Children and Adolescents. National Institute for Health and Medical Research (INSERM). Available online at https://www.ncbi.nlm.nih.gov/books/NBK7133/pdf/Bookshelf_NBK7133.pdf. Accessed on February 10, 2017.
- 6.Knopf DM, Park J, Mulye TP. The Mental Health of Adolescents: A National Profile, 2008. National Adolescent Health Information Center. Available online at http://nahic.ucsf.edu/downloads/MentalHealthBrief.pdf. Accessed on February 10, 2017.
- 8.Pastor PN, Reuben CA. Diagnosed Attention Deficit Hyperactivity Disorder and Learning Disability: United States, 2004–2006. Vital and Health Statistics, Series 10. 2008;Jul.(237):1–14.Google Scholar
- 9.Vestal C. Medicaid ADHD Treatment Under Scrutiny. The Pew Charitable Trusts. Available online at http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2014/10/08/medicaid-adhd-treatment-under-scrutiny. Accessed on February 10, 2017.
- 10.Grohol JM. Is ADHD Overdiagnosed? Yes & No. PsychCentral. Available online at http://psychcentral.com/blog/archives/2013/11/21/is-adhd-overdiagnosed-yes-no/. Accessed on February 10, 2017.
- 12.Akinbami LJ, Liu X, Pastor PN, et al. Attention Deficit Hyperactivity Disorder among Children Aged 5–17 Years in the United States, 1998–2009. NCHS Data Brief. 2011;Aug(70):1–8.Google Scholar
- 13.Morbidity and Mortality Weekly Report (MMWR). Mental Health Surveillance among Children -- United States, 2005-2011. Centers for Disease Control and Prevention. Available online at https://www.cdc.gov/mmwr/preview/mmwrhtml/su6202a1.htm. Accessed on February 10, 2017.
- 18.Mosby S. Mosby's Medical Dictionary, Eighth Edition. St. Louis, MO: Elsevier Health Sciences, 2009.Google Scholar
- 20.Federal and State Initiatives. Workforce Maps by State. American Academy of Child & Adolescent Psychiatry. Available online at https://www.aacap.org/AACAP/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspx. Accessed on February 10, 2017.
- 23.Advocacy. Prescriptive Authority. APA Practice Organization. Available online at http://www.apapracticecentral.org/advocacy/authority/index.aspx. Accessed on February 10, 2017.
- 24.Legislation/Regulation. State Practice Environment. American Association of Nurse Practioners. Available online at https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment. Accessed on February 10, 2017.
- 26.Levinson DR. Executive Summary: Second-Generation Antipsychotic Drug Use among Medicaid-Enrolled Children: Quality-of-Care Concerns. U.S. Department of Health & Human Services. Available online at https://oig.hhs.gov/oei/reports/oei-07-12-00320.pdf. Accessed on February 10, 2017.
- 29.CMS Statistics Reference Booklet, 2015 Edition. Medicaid and CHIP Enrollment. Centers for Medicare & Medicaid Services. Available online at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Statistics-Reference-Booklet/Downloads/2015CMSStatistics.pdf#page=21. Accessed on February 10, 2017.
- 30.Levinson DR. Access to Care: Provider Availability in Medicaid Managed Care. U.S. Department of Health & Human Services. Available online at https://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf. Accessed on February 10, 2017.
- 31.Anderson P. Economic Burden of Mental Illness Closes in on $200 Billion. Medscape. Available online at https://www.medscape.com/viewarticle/576221. Accessed on February 10, 2017.
- 32.Medicaid. Mental Health Financing in the United States: A Primer. Kaiser Family Foundation. Available online at https://www.kff.org/medicaid/report/mental-health-financing-in-the-united-states/. Accessed on February 10, 2017.
- 33.Pires S, Grimes K, Allen KD, et al. Examining Children’s Behavioral Health Service Utilization and Expenditures. Center for Health Care Strategies, Inc. Available online at https://www.chcs.org/media/Faces-of-Medicaid_Examining-Childrens-Behavioral-Health-Service-Utilization-and-Expenditures1.pdf. Accessed on February 10, 2017.
- 35.Medicaid Data Sources. Medicaid Analytic eXtract (MAX) General Information. Centers for Medicare & Medicaid Services. Available online at https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo/maxgeneralinformation.html. Accessed on February 10, 2017.
- 36.CMS Data. Medicaid Analytic Extracts (MAX). Research Data Assistance Center. Available online at https://www.resdac.org/cms-data/file-family/Medicaid-Analytic-Extracts-MAX. Accessed on February 10, 2017.
- 37.Drug Claims Processing. FDB MedKnowledge. First Databank. Available online at http://www.fdbhealth.com/. Accessed on February 10, 2017.
- 39.Data & Statistics. Attention-Deficit/Hyperactivity Disorder (ADHD). Centers for Disease Control and Prevention. Available online at: https://www.cdc.gov/ncbddd/adhd/data.html. Accessed on February 10, 2017.
- 41.Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007–1022.CrossRefGoogle Scholar
- 42.Epstein R, Fonnesbeck C, Williamson E, et al. Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents. Agency for Healthcare Research and Quality: Comparative Effectiveness Reviews. Available online at https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079669/pdf/PubMedHealth_PMH0079669.pdf. Accessed on February 10, 2017.
- 45.Mukolo A, Heflinger CA, Wallston K. The Stigma of Childhood Mental Disorders: A Conceptual Framework. Journal of the American Academy of Child & Adolescent Psychiatry. 2010;49(2):92–103.Google Scholar
- 46.Stuhec M, Munda B, Svab V, et al. Comparative Efficacy and Acceptability of Atomoxetine, Lisdexamfetamine, Bupropion and Methylphenidate in Treatment of Attention Deficit Hyperactivity Disorder in Children and Adolescents: A Meta-Analysis with Focus on Bupropion. Journal of Affective Disorders. 2015;178(6):149–59.CrossRefGoogle Scholar
- 48.Levinson DR. States' Collections of Rebates for Drugs Paid through Medicaid Managed Care Organizations. U.S. Department of Health & Human Services. Available online at https://oig.hhs.gov/oei/reports/oei-03-11-00480.pdf. Accessed on February 10, 2017.
- 49.Bruen B, Young K.What Drives Spending and Utilization on Medicaid Drug Benefits in States?. Kaiser Family Foundation. Available online at https://www.kff.org/medicaid/issue-brief/what-drives-spending-and-utilization-on-medicaid-drug-benefits-in-states/. Accessed on February 10, 2017.