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By Sarah C. Threnhauser, MPA

One in 68.

By now we’re all familiar with the stat. An estimated one in every 68 children are diagnosed with an autism spectrum disorder (ASD). Last year, a Centers for Disease Control and Prevention (CDC) analysis reported that overall rates have remained stable the past few years after increasing from one in 88 children in 2008 (see Prevalence Of Autism Among U.S. Children Now 1 In 68). It isn’t surprising that this increase in prevalence has been accompanied by another sharp increase – new data shows health care spending for consumers with ASD is also rising.

Between 2007 and 2012, mean cost for health care services for children with ASD increased by 19% — from $8,759.24 annually to $10,819.50 annually — with costs for mental health services increasing by 16% and costs for outpatient services increasing by 54% during the same period. This increase in costs was accompanied by an increase in utilization, with the annual average number of outpatient visits increasing by 36% — from 11.1 visits per year between 2007-2009, to 15.1 visits per year between 2010-2012 (see Average Cost Of Health Services For Children With Autism Increased 19% Post Parity Implementation). And the number of youth with autism visiting the emergency department (ED) increased by 500% between 2005 and 2013, from 3% of youth with autism making an ED visit in 2005 to 16% of youth in 2013 (see Adolescents With Autism 4 Times More Likely To Visit Emergency Department).

For adults with ASD, these statistics don’t get any better. Over the next decade, a half a million youth with ASD will enter adulthood (see 500,000 Youth With Autism Will Enter Adulthood By 2025) and they will remain a service-intensive population. In a recent study, Medicaid-enrolled adults with ASD had high rates of psychiatric comorbidity (81%), epilepsy (22%), infections (22%), skin disorders (21%), and hearing impairments (18%) — leading to more outpatient office visits (32% vs 8% for the general population) and prescription drug use claims (51% vs 24%), emergency room costs ($15,929 vs $2,598), prescription drug costs ($6,067 vs $3,144), and total expenditures ($13,700 vs $8,560). (For more on those numbers, see Comorbidity Prevalence, Healthcare Utilization, And Expenditures Of Medicaid Enrolled Adults With Autism Spectrum Disorders.)

For payer organizations, these stats present a new challenge; for provider organizations, an opportunity. As the prevalence rates have increased, many states have made moves to provide move coverage for their citizens by mandating coverage of applied behavioral analysis (ABA) and other services for children and youth with autism (see Keeping Up With The New Developments In The Autism Market). These mandates, in combination with federal parity legislation and health care reform, has resulted in more consumers having coverage for more services – leaving health plans with new service requirements and higher costs.

This is where the opportunity comes into play for provider organizations – health plans are looking for organizations that can deliver the mandated services while keeping costs down. To position your organization to take advantage of this opportunity, I would recommend executive teams start by reviewing your state’s requirements around ABA and other autism-related services. States have different restrictions and requirements related to how services are provided, licensure for who can provide services, annual limits on coverage, and age limits on who is mandated to receive treatment. Understanding the environment that health plans are working in will help you to understand how to best position your organization to meet their needs. (For a state-by-state analysis of autism insurance mandates, see What States Mandate ABA Benefits For Autism Spectrum Disorder?: An OPEN MINDS Market Intelligence Report.)

Next, consider the service opportunities that will lower costs for consumers with ASD. Health plans are looking for services that are evidence- and community-based, including intensive in-home treatment services for individuals with ASD who meet basic criteria for severe autism, ABA home and school settings, and wrap around support services (see The Growing Opportunity For Community-Based Services For Autism and Caring For Patients With ASD & Their Caregivers: Federal & State Autism-Specific Insurance Reform). There is also a growing acceptance in the use of technology to support consumers with autism – from online programs to teach social and communication skills, to apps that support the development of fine motor skills. These technologies have the potential to offer supplemental support to consumers at a lower cost (see The Use of Technology in Treatment of Autism Spectrum Disorders).

The prevalence of children needing services will only continue to grow – creating a new space for provider organizations to grow and develop new services. Looking to develop new services for this market — or maybe another? Join OPEN MINDS on September 28 for the session, “Diversifying Your Revenue Streams: How To Successfully Launch A New Service Line,” with OPEN MINDS Senior Associate Joe Naughton-Travers at The 2017 OPEN MINDS Executive Leadership Retreat in Gettysburg, Pennsylvania.


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