Skip to main content
By Monica E. Oss

The new autism prevalence estimates are out from the Centers for Disease Control and Prevention (CDC)—1 in 59 children are estimated to have autism spectrum disorder (ASD) according to the CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network, up from previous estimates of 1 in 68 in 2014 (see Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years – Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014). ADDM’s surveillance was done from 2000 to 2014, and during that time, prevalence estimates increased from 6.7 to 16.8 per 1,000 children aged eight years, approximately 150%.

When I read these prevalence numbers, I always ask “why”? Are there really more people with autism—and if so, why? Is “diagnosis” of autism more likely now than in the recent past? Is this an “epidemic”? Last year, a Scientific American article noted that the rise in reported prevalence (which is different than the actual prevalence), carries with it certain assumptions (see The Real Reasons Autism Rates Are Up in the U.S.). Most notably, the CDC relies on school and medical records that are probably incomplete, the definition of autism changes with each new iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the combined results of less institutionalization and better diagnoses are revealing children that were there all along.

Lora Perry
Lora Perry

For an expert perspective, I turned to my colleague and OPEN MINDS subject expert, Lora Perry. Her take? Better surveillance.

I certainly agree there is no evidence of an autism “epidemic.” Rather, the increasing numbers are a tribute to the determination of those entrusted with improving public health to find more and better ways to be accurate in our estimates of prevalence. But, since we still don’t know what causes autism (latest thinking is autism presents in the presence of genetic anomalies combined with an exposure to some sort of toxin in utero, such as a virus), we really can’t say whether the numbers will continue to rise. To truly know the answers, our ability to measure must become more precise. If a blood test, or MRI, or similar test could diagnose ASD, that would be wonderful, and would expand our diagnostic capabilities. Screening for ASD is fairly simple and should be part of a wellness check for children, starting at 18 months. In my experience, Medicaid and commercial health insurance will pay for the diagnostic assessment.

Regardless of the reason, the increasing proportion of the population with an ASD has big implications for the health care system. Annual health care costs for adults with ASD are about 55% higher than costs for the general population, with mean costs of $7,119 per consumer per year versus $3,197 per consumer per year for the general population (see Annual Health Care Costs For Adults With Autism 55% Higher Than General Population).

The utilization patterns look similar to those of other consumer groups with cognitive disorders. Consumers with ASD had a larger overall percentage of inpatient hospitalizations—5.6% for those with ASD and 3.2% for the general population. This group also had a larger percentage of outpatient visits—86.2% for those with ASD compared to 70.7% for the general population. Medication usage was also higher—79.6% for those with ASD, compared to 61.8% for the general population.

These new research studies on increasing prevalence of autism and the health care cost differential for consumers with autism suggest some new market opportunities. First, there will be continued demand for the services used to address ASD. Provider organizations with programs meeting this need will find continued demand. Second, the health care needs of people with autism are the greater opportunity. The differential in health care spending between with consumers with ASD and the general population has the attention of payers and health plans.

As I wrote about in my article, Riding The Value-Based Wave, in last month’s OPEN MINDS Management Newsletter, I think the future health plan opportunities for specialist organizations is going to be focused on two ends of the service delivery spectrum—community-based care to keep consumers from being admitted to acute care settings, and support services to transition consumers to the community after an acute care stay. This applies to provider organizations serving consumers with ASD. The first model is the specialty medical home “on steroids” so to speak—the domain of provider organizations that can manage consumers with complex behavioral/cognitive disorders and keep them out of acute care settings.

“Manage” is more extensive here, and means managing behavioral, physical, pharmacy, and social services in community-based and home-based settings, on some type of per member per month (PMPM) basis with upside/downside risk based on total spending or related parameters. I think the preferred model will morph in the decade ahead with health plans looking for an organization that can accept a PMPM payment for both care coordination and the provision of home-based/outpatient primary care, behavioral health, and social supports.

The second model is focused on cost-effective crisis management. Health plans need provider organizations with the ability to provide acute stabilization for consumers with complex behavioral/cognitive disorders. But, facility-based acute stabilization is not enough—the model will prefer a provider organization that can coordinate and support the consumer’s return to the community, on some form of episodic, bundled, or case rate payment.

For more, check out my colleague Sarah Threnhauser’s article on the higher levels of services and supports necessary for this group, including a wide prevalence of co-occurring conditions and complications (see New Opportunities Serving Adults With Autism). And, for our latest coverage of serving consumer with ASD, check out these resources from the OPEN MINDS Industry Library:

  1. Medicaid Cost For Autism – The Impact Of Special Education Funds
  2. States Make Autism Coverage For Children A Priority
  3. Finding The Opportunities In Serving The 1 In 68
  4. Keeping Up With The New Developments In The Autism Market
  5. 2018 Children & Youth Services Market Update
  6. EEG Signals Accurately Predict Autism As Early As 3 Months Of Age
  7. Otsimo Expands Autism Education App In U.S.
  8. Halifax Partners With ChanceLight Behavioral Health, Therapy & Education
  9. Autism Evaluations Conducted Via Telemedicine Nearly As Accurately As In-Person Assessment
  10. Blackstone To Acquire Center For Autism & Related Disorders

For more on this topic, join OPEN MINDS Senior Associate Annie Medina on August 14 for her Executive Summit session, “Designing & Implementing Innovative Treatment Programs: An OPEN MINDS Executive Summit & Showcase,” at The 2018 OPEN MINDS Management Best Practices Institute.

Login to access The OPEN MINDS Circle Library. Not a member? Create your free account now!


Support Request

Need help now?

Call our toll-free phone number 877-350-6463