Does a claims diagnosis of autism mean a true case?

The purpose of this study was to validate autism spectrum disorder cases identified through claims-based case identification algorithms against a clinical review of medical charts. Charts were reviewed for 432 children who fell into one of the three following groups: (a) more than or equal to two claims with an autism spectrum disorder diagnosis code (n = 182), (b) one claim with an autism spectrum disorder diagnosis code (n = 190), and (c) those who had no claims for autism spectrum disorder but had claims for other developmental or neurological conditions (n = 60). The algorithm-based diagnoses were compared with documented autism spectrum disorders in the medical charts. The algorithm requiring more than or equal to two claims for autism spectrum disorder generated a positive predictive value of 87.4%, which suggests that such an algorithm is a valid means to identify true autism spectrum disorder cases in claims data.

How states use Medicaid to fund community-based services to children with autism spectrum disorders.

OBJECTIVE: This study examined the extent to which state Medicaid agencies funded 16 services for children with autism spectrum disorders: individual therapy, physical and occupational therapy, in-home supports, speech therapy, diagnostic assessment, behavior modification, family therapy, case management, targeted case management, respite, day treatment, social skills training, habilitation services, treatment planning, family education and training, and assistive communication devices. METHODS: Procedure codes in the Medicaid Analytic eXtract (MAX) "other therapies" file were used to identify community-based services commonly delivered to children with a diagnosis of a primary autism spectrum disorder. RESULTS: Four services are commonly used to address the core deficits of these disorders: physical and occupational therapy, speech therapy, behavior modification, and social skills training. Only six states funded all four services. CONCLUSIONS: States varied considerably in use of Medicaid to reimburse these services, indicating that some states may have opportunities to receive federal matching funds.

Healthcare service use and costs for autism spectrum disorder: a comparison between medicaid and private insurance.

Healthcare costs and service use for autism spectrum disorder (ASD) were compared between Medicaid and private insurance, using 2003 insurance claims data in 24 states. In terms of costs and service use per child with ASD, Medicaid had higher total healthcare costs ($22,653 vs. $5,254), higher ASD-specific costs ($7,438 vs. $928), higher psychotropic medication costs($1,468 vs. $875), more speech therapy visits (13.0 vs. 3.6 visits), more occupational/physical therapy visits (6.4 vs. 0.9 visits), and more behavior modification/social skills visits (3.8 vs. 1.1 visits) than private insurance (all p < 0.0001). In multivariate analysis, being enrolled in Medicaid had the largest effect on costs, after controlling for other variables. The findings emphasize the need for continued efforts to improve private insurance coverage of autism.

Age-related variation in health service use and associated expenditures among children with autism.

This study examined differences by age in service use and associated expenditures during 2005 for Medicaid-enrolled children with autism spectrum disorders. Aging was associated with significantly higher use and costs for restrictive, institution-based care and lower use and costs for community-based therapeutic services. Total expenditures increased by 5 % with each year of age; by 23 % between 3-5 and 6-11 year olds, 23 % between 6-11 and 12-16, and 14 % between 12-16 and 17-20 year olds. Use of and expenditures for long-term care, psychiatric medications, case management, medication management, day treatment/partial hospitalization, and respite services increased with age; use of and expenditures for occupational/physical therapy, speech therapy, mental health services, diagnostic/assessment services, and family therapy declined.

Emerging perspectives on adolescents and young adults with high-functioning autism spectrum disorders, violence, and criminal law.

As the prevalence of autism spectrum disorders (ASDs) has increased, attention has shifted toward consideration of ASDs in adolescence and adulthood, as well as public health repercussions for this population. Since the social and emotional deficits within ASDs may be salient during incidents of unintended criminal or violent behavior, one area of focus is involvement of adolescents and young adults with ASD in the criminal justice system. Without a thorough understanding of how and why individuals with ASDs may exhibit criminal behavior, judicial and legislative state systems have begun to develop policies lacking a substantial evidence base. In this article, we attempt to synthesize the literature on one type of ASD (high functioning) and criminal behavior. Three specific deficits characteristic of individuals with ASDs (theory of mind, emotion regulation, and moral reasoning) are examined as potential confluent forces leading to criminal behavior among individuals with ASDs. Legal and policy recommendations are presented.

The interplay of outpatient services and psychiatric hospitalization among Medicaid-enrolled children with autism spectrum disorders.

OBJECTIVE: To examine whether increased provision of community-based services is associated with decreased psychiatric hospitalizations among children with autism spectrum disorders (ASDs). DESIGN: Retrospective cohort study using discrete-time logistic regression to examine the association of service use in the preceding 60 days with the risk of hospitalization. SETTING: The Medicaid-reimbursed health care system in the continental United States. PARTICIPANTS: Medicaid-enrolled children with an ASD diagnosis in 2004 (N = 28 428). MAIN EXPOSURES: Use of respite care and therapeutic services, based on procedure codes. MAIN OUTCOME MEASURES: Hospitalizations associated with a diagnosis of ASD (International Classification of Diseases, 10th Revision, codes 299.0, 299.8, and 299.9). RESULTS: Each $1000 increase in spending on respite care during the preceding 60 days resulted in an 8% decrease in the odds of hospitalization in adjusted analysis. Use of therapeutic services was not associated with reduced risk of hospitalization. CONCLUSIONS: Respite care is not universally available through Medicaid. It may represent a critical type of service for supporting families in addressing challenging child behaviors. States should increase the availability of respite care for Medicaid-enrolled children with ASDs. The lack of association between therapeutic services and hospitalization raises concerns regarding the effectiveness of these services.

Prevalence and correlates of autism in a state psychiatric hospital.

This study estimated the ASD prevalence in a psychiatric hospital and evaluated the Social Responsiveness Scale (SRS) combined with other information for differential diagnosis. Chart review, SRS and clinical interviews were collected for 141 patients at one hospital. Diagnosis was determined at case conference. Receiver operating characteristic (ROC) curves were used to evaluate the SRS as a screening instrument. Chi-squared Automatic Interaction Detector (CHAID) analysis estimated the role of other variables, in combination with the SRS, in separating cases and non-cases. Ten percent of the sample had ASD. More than other patients, their onset was prior to 12 years of age, they had gait problems and intellectual disability, and were less likely to have a history of criminal involvement or substance abuse. Sensitivity (0.86) and specificity (0.60) of the SRS were maximized at a score of 84. Adding age of onset < 12 years and cigarette use among those with SRS <80 increased sensitivity to 1.00 without lowering specificity. Adding a history substance abuse among those with SRS >80 increased specificity to 0.90 but dropped sensitivity to 0.79. Undiagnosed ASD may be common in psychiatric hospitals. The SRS, combined with other information, may discriminate well between ASD and other disorders.

Access and outcomes for persons with psychotic and affective disorders receiving vocational rehabilitation services.

OBJECTIVE: This study examined the extent to which individuals with psychotic and affective disorders have access to vocational rehabilitation (VR) services and their employment and entitlement outcomes relative to persons with other disabilities. METHODS: National Rehabilitation Services Administration data were used for individuals who applied for VR services and whose cases were closed in 2005-2007. The sample included persons with psychotic disorders (N=59,137), affective disorders (N=153,859), and other disabilities (N=652,829). RESULTS: Persons with psychiatric disabilities were less likely to get full access to VR services and had lower competitive employment rates at case closure compared with those with other disabilities. CONCLUSIONS: Individuals with psychotic and affective disorders had less access to the full complement of VR services and poorer outcomes. Implications include the need for additional training of VR providers to help them better meet the vocational needs of this population and greater support from mental health providers.

Age of diagnosis among Medicaid-enrolled children with autism, 2001-2004.

OBJECTIVE: This study examined child- and county-level factors associated with age of diagnosis of autism among Medicaid-enrolled children and the change in age of diagnosis over time. METHODS: National Medicaid claims from 2002 to 2004 were used to identify age of diagnosis and characteristics of children younger than ten years old with a diagnosis of autism (ICD-9 codes 299, 299.0x, or 299.8x). These data were linked to county-level education and health care variables. Linear regression with random effects for state and county was used to examine associations between these variables and age of diagnosis. RESULTS: A total of 28,722 Medicaid-enrolled children newly diagnosed with an autism spectrum disorder were identified. Their average age of diagnosis was 64.9 months. Adjusted average age of diagnosis dropped 5.0 months for autistic disorder and 1.8 months for other spectrum disorders during the study period. Asian children were diagnosed earlier than children in other racial or ethnic groups, although these differences were much more pronounced for other spectrum disorders than for autistic disorder. Children eligible for Medicaid through the poverty category were diagnosed earlier, on average, than children who were eligible through disability, foster care, or other reasons, although this difference decreased over time. Children in large urban or rural counties were diagnosed later than children in small urban or suburban counties. CONCLUSIONS: Findings showed that diagnosis of autism occurs much later than it should among Medicaid-enrolled children, although timeliness is improving over time. Analyses suggest that most of the observed variation is accounted for by child-level variables, rather than county-level resources or state policies.

Use of vocational rehabilitative services among adults with autism.

This study examined the experiences of individuals with autism spectrum disorders (ASD) in the US Vocational Rehabilitation System (VRS). Subjects included all 382,221 adults ages 18-65 served by this system whose cases were closed in 2005; 1,707 were diagnosed with ASD. Adults with ASD were more likely than adults with other impairments to be denied services because they were considered too severely disabled. Among those served, adults with ASD received the most expensive set of services. They and adults with MR were most likely to be competitively employed at case closure. Post hoc analyses suggest that their employment was highly associated with on-the-job supports. The results suggest the importance of the VRS in serving adults with ASD.