CH B AR THE LEONARD DAVIS INSTITUTE R ES E RI EF of HEALTH ECONOMICS 12 Penn LDI 20 16 . - No Effects of Autism Spectrum Disorder Insurance Mandates on the Treated Prevalence of Autism Spectrum Disorder David S. Mandell, Colleen L. Barry, Steven C. Marcus, Ming Xie, Kathleen Shea, Katherine Mullan, Andrew J. Epstein JAMA Pediatrics, July 2016, Online First KEY FINDINGS: State mandates requiring commercial health plans to cover services for children with autism spectrum disorder increased the number of children diagnosed with the disorder. However, diagnosis rates remain much lower than LDI RESEARCH BRIEF community estimates, suggesting that many commercially insured children with ASD remain undiagnosed or are insured through public plans. THE QUESTION implement a mandate in 2001, followed by three states in 2008 (Illinois, South Carolina, and Texas), before the start of the Responding to the growing prevalence of autism spectrum study. During the study period, mandates were implemented disorder (ASD) among children, and insurer reluctance to by six states in 2009 (Arizona, Florida, Louisiana, New pay for expensive treatments, 44 states now have mandates Mexico, Pennsylvania, and Wisconsin), four states in 2010 requiring commercial plans to cover behavioral services for (Colorado, Connecticut, Montana, and New Jersey), eight children with ASD. These mandates apply to state-regulated states in 2011 (Arkansas, Kentucky, Massachusetts, Maine, plans but do not apply to large, self-insured employer group Missouri, New Hampshire, Nevada, and Vermont), and plans, which are federally-regulated. The state mandates seven states in 2012 (California, Delaware, Michigan, New vary in terms of the age ranges they cover and the kinds of York, Rhode Island, Virginia, and West Virginia). All state plans to which they apply. mandates applied to fully insured firms with more than 50 employees; 22 of the 29 state mandates also applied to fully Insurers have opposed the mandates, which they claimed insured firms with 50 or fewer employees. By the end of would dramatically increase the number of children diagnosed the study period, 18 of the 29 mandates covered individuals with ASD and drastically increase health spending. ASD is from birth through 18 years or older. thought to be underdiagnosed with its treated prevalence – the number of individuals diagnosed with ASD in the health Of the more than one million children in the claims data care system – far below the Centers for Disease Control and sample, the authors identified 154,089 children diagnosed Prevention’s estimated community prevalence of 15 per with ASD. Controlling for time trends and demographic 1,000 children. But little is known about the actual effects of factors, the study found that implementation of a mandate these mandates. David Mandell and colleagues used claims was associated with an increase of 12.7% in the treated data from three large national insurers to analyze the effects prevalence of eligible children with ASD over the study of state mandates on the rate at which commercially insured period, with the effects building over time — 10.4% in the children are diagnosed with ASD. first year of the mandate, 17.1% in the second year, and 18.0% in the third and later years. The adjusted prevalence rate was 1.8 per 1,000 children in states with ASD insurance THE FINDINGS mandates and 1.6 per 1,000 children in states without such a mandate. Twenty-nine states had ASD insurance mandates during the study period, 2008-2013. Indiana was the first state to Research to Improve the Nation’s Health System. DATA DRIVEN. POLICY FOCUSED. ldi.upenn.edu THE IMPLICATIONS groups of children who would and would not be affected by the laws based on the source of their health insurance and their These findings indicate that the mandates are having their age. They compared four groups of children: those in states intended effects, and that those effects build over time. But with active ASD insurance mandates, who were subject to even three years or more after implementation, the treated the mandate; those in states with an active mandate who were prevalence of ASD was much lower than community not subject to the mandate; those in states without a mandate prevalence estimates. This finding may allay concerns that who would have been subject to the mandate if one were mandates will substantially increase insurance costs, but active; and those in states without a mandate who would not it suggests that many commercially insured children with have been subject to the mandate if one were active. The use ASD remain undiagnosed or are being treated only through of comparison groups of children in states without mandates publicly funded systems. accounted for secular trends in treated prevalence unrelated to state ASD mandate laws. In addition, the authors looked at It is clear that the mandates have not had the full effect whether the effect of the mandates changed over time, based on that advocates desired. The authors note that the shortfall how many years a law had been in place. might be due to vague and difficult regulatory processes that LDI RESEARCH BRIEF providers must follow, low reimbursements for assessment Mandell DS, Barry CL, Marcus SC, Xie M, Shea K, Mullan K, Epstein AJ. and treatment, and a shortage of qualified clinicians to meet Effects of Autism Spectrum Disorder Insurance Mandates on the Treated Prevalence of Autism Spectrum Disorder. JAMA Pediatrics. Published online the growing demand for ASD-related care. The results July 11, 2016. doi:10.1001/jamapediatrics.2016.1049. suggest the need for additional strategies to enforce the mandates and address regulatory and health system-related barriers that inhibit the timely and appropriate identification LEAD AUTHOR: DR. DAVID S. MANDELL of children with ASD. David S. Mandell, ScD is Professor of Mental Health Services Research in Psychiatry at THE STUDY Penn, where he directs the Center for Mental Health Policy and Services Research. He is also The authors used combined claims data (assembled by Associate Director of the Center for Autism the Health Care Cost Institute) from three large, national Research at The Children’s Hospital of Philadelphia. The goal health insurance companies: United Healthcare, Aetna and of his research is to improve the quality of care that individuals Humana. They identified 154,089 children (birth through 21 with autism receive in their communities. He examines, at the years) diagnosed with ASD during the five-year study period state and national level, the effects of different strategies to from January 2008 through December 2012. To identify organize, finance and deliver services on service use patterns whether a child resided in a state with an implemented and outcomes. He also conducts experimental studies to ASD mandate law, they compiled detailed information determine the best ways to successfully implement efficacious from Autism Speaks about state mandates, and verified the practices in community settings. Dr. Mandell holds a bachelor information by reviewing the original mandate laws. of arts in psychology from Columbia University and a doctorate of science from the Johns Hopkins School of Hygiene and They compared the treated prevalence of ASD within states Public Health. before and after mandate implementation, and between Connect With Us: ldi.upenn.edu Since 1967, the Leonard Davis Institute of Health Economics (LDI) has been the leading university institute dedicated to data-driven, • ldi.upenn.edu/health-policysense policy-focused research that improves our nation’s health and health • @PennLDI care. 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