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Prescription Drug Use and Cost Trends Among Medicaid-Enrolled Children with Disruptive Behavioral Disorders

  • Lirong Zhao
  • Caitlin Cross-Barnet
  • Vetisha L. McClair
Article

Abstract

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.

Notes

Acknowledgements

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.

Disclaimer

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.

References

  1. 1.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Arlington, VA: American Psychiatric Association, 1994.Google Scholar
  2. 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. 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. 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. 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. 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.
  7. 7.
    Visser SN, Bitsko RH, Danielson ML, et al. Treatment of Attention Deficit/Hyperactivity Disorder among Children with Special Health Care Needs. The Journal of Pediatrics. 2015;166(6):1423–1430.CrossRefGoogle Scholar
  8. 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. 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. 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.
  11. 11.
    Pescosolido BA, Perry BL, Martin JK, et al. Stigmatizing Attitudes and Beliefs about Treatment and Psychiatric Medications for Children with Mental Illness. Psychiatric Services. 2007;58(5):613–618.CrossRefGoogle Scholar
  12. 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. 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.
  14. 14.
    Kataoka SH, Zhang L, Wells KB. Unmet Need for Mental Health Care among U.S. Children: Variation by Ethnicity and Insurance Status. The American Journal of Psychiatry. 2002;159(9):1548–1555.CrossRefGoogle Scholar
  15. 15.
    McLaughlin KA, Hilt LM, Nolen-Hoeksema S. Racial/Ethnic Differences in Internalizing and Externalizing Symptoms in Adolescents. Journal of Abnormal Child Psychology. 2007;35(5):801–816.CrossRefGoogle Scholar
  16. 16.
    Walton JR, Mautone JA, Nissley-Tsiopinis J, et al. Correlates of Treatment Engagement in an ADHD Primary Care-Based Intervention for Urban Families. The Journal of Behavioral Health Services & Research. 2014;41(4):539–547.CrossRefGoogle Scholar
  17. 17.
    Banta JE, James S, Haviland MG, et al. Race/Ethnicity, Parent-Identified Emotional Difficulties, and Mental Health Visits among California Children. The Journal of Behavioral Health Services & Research. 2013;40(1):5–19.CrossRefGoogle Scholar
  18. 18.
    Mosby S. Mosby's Medical Dictionary, Eighth Edition. St. Louis, MO: Elsevier Health Sciences, 2009.Google Scholar
  19. 19.
    Thomas CR, Holzer CE. The Continuing Shortage of Child and Adolescent Psychiatrists. Journal of the American Academy of Child & Adolescent Psychiatry. 2006;45(9):1023–1031.CrossRefGoogle Scholar
  20. 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.
  21. 21.
    Epstein JN, Kelleher KJ, Baum R. Variability in ADHD Care in Community-Based Pediatrics. Pediatrics. 2014;134(6):1136–1143.CrossRefGoogle Scholar
  22. 22.
    Pidano AE. Pediatric Psychopharmacology: Context, Model Programs, and Considerations for Care. Psychiatric Services. 2012;63(9):929–934.CrossRefGoogle Scholar
  23. 23.
    Advocacy. Prescriptive Authority. APA Practice Organization. Available online at http://www.apapracticecentral.org/advocacy/authority/index.aspx. Accessed on February 10, 2017.
  24. 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.
  25. 25.
    Visser SN, Danielson ML, Bitsko RH. Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry. 2014;53(1):34–62.CrossRefGoogle Scholar
  26. 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.
  27. 27.
    Olfson M, Blanco C, Liu L, et al. National Trends in the Outpatient Treatment of Children and Adolescents with Antipsychotic Drugs. Archives of General Psychiatry. 2006;63(6):679–685.CrossRefGoogle Scholar
  28. 28.
    Olfson M, Blanco C, Liu S, et al. National Trends in the Office-Based Treatment of Children, Adolescents, and Adults with Antipsychotics. Archives of General Psychiatry. 2012;69(12):1247–1256.CrossRefGoogle Scholar
  29. 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. 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. 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. 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. 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.
  34. 34.
    Cuffel B. Disruptive Behavior and the Determinants of Costs in the Public Mental Health System. Psychiatric Services. 1997;48(12):1562–1566.CrossRefGoogle Scholar
  35. 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. 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. 37.
    Drug Claims Processing. FDB MedKnowledge. First Databank. Available online at http://www.fdbhealth.com/. Accessed on February 10, 2017.
  38. 38.
    Hux JE, Ivis F, Flintoft V, et al. Diabetes in Ontario: Determination of Prevalence and Incidence Using a Validated Administrative Data Algorithm. Diabetes Care. 2002;25(3):512–516.CrossRefGoogle Scholar
  39. 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.
  40. 40.
    Zuvekas SH, Vitiello B. Stimulant Medication Use in Children: A 12-Year Perspective. The American Journal of Psychiatry. 2012;169(2):160–166.CrossRefGoogle Scholar
  41. 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. 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.
  43. 43.
    Berkout OV, Young JN, Gross AM. Mean Girls and Bad Boys: Recent Research on Gender Differences in Conduct Disorder. Aggression and Violent Behavior. 2011;16(6):503–511.CrossRefGoogle Scholar
  44. 44.
    Hinshaw SP. The Stigmatization of Mental Illness in Children and Parents: Developmental Issues, Family Concerns, and Research Needs. Journal of Child Psychology and Psychiatry. 2005;46(7):714–734.CrossRefGoogle Scholar
  45. 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. 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
  47. 47.
    Hanwella R, Senanayake M, de-Silva V. Comparative Efficacy and Acceptability of Methylphenidate and Atomoxetine in Treatment of Attention Deficit Hyperactivity Disorder in Children and Adolescents: A Meta-Analysis. BMC Psychiatry. 2011;10(11):176.CrossRefGoogle Scholar
  48. 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. 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.
  50. 50.
    Gorina Y, Kramarow EA. Identifying Chronic Conditions in Medicare Claims Data: Evaluating the Chronic Condition Data Warehouse Algorithm. Health Services Research. 2011;46(5):1610–1627.CrossRefGoogle Scholar
  51. 51.
    West JC, Rae DS, Huskamp HA, et al. Medicaid Medication Access Problems and Increased Psychiatric Hospital and Emergency Care. General Hospital Psychiatry. 2010;32(6):615–622.CrossRefGoogle Scholar
  52. 52.
    Fremont WP, Nastasi R, Newman N, et al. Comfort Level of Pediatricians and Family Medicine Physicians Diagnosing and Treating Child and Adolescent Psychiatric Disorders. International Journal of Psychiatry in Medicine. 2008;38(2):153–168.CrossRefGoogle Scholar
  53. 53.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Arlington, VA: American Psychiatric Association, 2013.CrossRefGoogle Scholar

Copyright information

© This is a U.S. government work and its text is not subject to copyright protection in the United States; however, its text may be subject to foreign copyright protection [YEAR]  2018

Authors and Affiliations

  • Lirong Zhao
    • 1
  • Caitlin Cross-Barnet
    • 1
  • Vetisha L. McClair
    • 1
  1. 1.Research and Rapid-Cycle Evaluation Group, Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid ServicesBaltimoreUSA

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