Research
Original Investigation
Total Direct Medical Expenses and Characteristics
of Privately Insured Adolescents Who Incur High Costs
Susan H. Gray, MD; Emily K. Trudell, MPH; S. Jean Emans, MD; Elizabeth R. Woods, MD, MPH;
Jay G. Berry, MD, MPH; Louis Vernacchio, MD, MSc
IMPORTANCE Accountable care payment models aim to reduce total direct medical expenses
Supplemental content at
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for high-cost patients through improved quality of care and preventive health services. Little
is known about health care expenditures of privately insured adolescents, especially those
who incur high costs.
OBJECTIVES To assess health care expenditures for high-cost adolescents and to describe the
patient characteristics associated with high medical costs.
DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort analysis was conducted of data
from January 1 to December 31, 2012, of 13 103 privately insured adolescents aged 13 to 21
years (mean [SD] age, 16.3 [2.4] years; 6764 [51.6%] males) at 82 independent pediatric
primary care practices in Massachusetts. Analysis was conducted from April 1, 2014, to April 1,
2015.
MAIN OUTCOMES AND MEASURES We compared demographic (age, sex, median income by
zip code) and clinical (obesity, behavioral health problem, complex chronic condition)
characteristics between high-cost (top 1%) and non–high-cost adolescents. We assigned
high-cost adolescents to clinical categories using software from the Agency for Healthcare
Research and Quality to describe clinically relevant patterns of spending.
RESULTS Total direct medical expenses were $41.2 million for the entire cohort and a median
$1167 per patient. A total of 132 (1.0%) patients with the highest costs accounted for 23.6% of
expenses of the cohort, with a median $52 577 per patient. Mental health disorders were the
most common diagnosis in high-cost patients; 78 (59.1%) of these patients had at least 1
behavioral health diagnosis. Pharmacy costs accounted for 28.4% of total direct medical
expenses of high-cost patients; primary care accounted for 1.0%. Characteristics associated
with being a high-cost patient included having 1 complex chronic condition (relative risk [RR],
6.5; 95% CI, 4.7-9.0), having 2 or more complex chronic conditions (RR, 23.5; 95% CI,
14.2-39.1), having any behavioral health diagnosis (RR, 3.6; 95% CI, 2.6-5.1), and obesity
(RR, 2.0; 95% CI, 1.3-3.0).
CONCLUSIONS AND RELEVANCE Total direct medical expenses for privately insured high-cost
adolescents are associated with medical complexity, mental health conditions, and obesity.
Cost reduction strategies in similar populations should be tailored to these cost drivers.
JAMA Pediatr. 2015;169(10):e152682. doi:10.1001/jamapediatrics.2015.2682
Author Affiliations: Division of
Adolescent and Young Adult
Medicine, Boston Children’s Hospital,
Boston, Massachusetts (Gray, Emans,
Woods); Department of Pediatrics,
Harvard Medical School, Boston,
Massachusetts (Gray, Emans, Woods,
Berry, Vernacchio); The Pediatric
Physicians’ Organization at Children’s,
Boston Children’s Hospital, Boston,
Massachusetts (Trudell, Vernacchio);
Division of General Pediatrics, Boston
Children’s Hospital, Boston,
Massachusetts (Berry, Vernacchio).
Corresponding Author: Susan H.
Gray, MD, Division of Adolescent and
Young Adult Medicine, Boston
Children’s Hospital, 333 Longwood
Ave, Fifth Floor, Boston, MA 02115
([email protected]).
(Reprinted) 1/7
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Research Original Investigation
Privately Insured Adolescents’ Health Care Costs
H
ealth care expenditures were 17.9% of the US gross
domestic product in 2011 and are projected to rise to
19.6% by 2021.1 Children and adolescents generally
have lower health care costs than adults, but little is known
about how specific conditions among adolescents are associated with health services that increase costs. Understanding
adolescents’ health care use and costs is important because
many chronic conditions, including obesity and mental
health disorders, that originate in adolescence are associated
with long-term increased morbidity and costs in adulthood.2-5 The influence of these chronic health conditions
relative to other health care costs for adolescents remains
unknown.
With the development of new health care payment models, there is a need to devise strategies to maintain or reduce
costs while meeting quality and performance standards.6 In
accountable care models, physicians receive information about
their patients’ clinical care and costs from payers. Physicians
also receive incentives for meeting quality benchmarks, and
they share savings for stabilizing or reducing costs.6 Massachusetts was one of the first states to implement accountable
care payment reform on a large scale.7
It is now well known that a small number of patients—
both children and adults—consume a disproportionate
amount of health care resources and generate a disproportionate amount of cost.8-15 To our knowledge, little has been
published about what characteristics or clinical conditions
in privately insured adolescents drive high health care
costs. In this study, we report the findings from 82 pediatric
primary care practices in Massachusetts that entered an
accountable care–style contract with a private insurer,
which allowed us to undertake this analysis. Our objectives
were to characterize total direct medical expenses (TDME)
for a primary care population of privately insured adolescents, and then identify the clinical diagnoses and health
care services that contribute the most to high-cost health
care.
Methods
Study Population and Setting
We analyzed data from paid medical and pharmacy claims
from January 1 to December 31, 2012, for all members
enrolled for 9 or more months in a large, nonprofit commercial health insurance plan who were aged 13 to 21 years (the
upper age limit for many practices) as of January 1, 2012.
They were patients of primary care providers (PCPs) from
the Pediatric Physicians’ Organization at Children’s, an independent association affiliated with Boston Children’s Hospital. Data usage agreements prohibit naming the insurance
plan in this article. The association consists of 82 pediatric
primary care practices ranging from 1 to 23 physicians.
Although they are independently owned, the practices collaborate in quality improvement. This project was approved
by the Boston Children’s Hospital Institutional Review
Board. Analysis was conducted from April 1, 2014, to April 1,
2015.
2/7
At a Glance
• We describe characteristics of high-cost patients among 13 103
privately insured adolescents in 82 pediatric primary care
practices in Massachusetts, to identify opportunities for
improving care quality or reducing costs.
• Few adolescents (132 [1.0%]) accounted for 23.6% of the direct
medical expenses, with a median of $52 577 per patient.
• Complex chronic conditions and mental health disorders were
the greatest predictors of high costs; 59.1% of high-cost patients
had at least 1 behavioral health diagnosis.
• Pharmacy costs accounted for 28.4% of total direct medical
expenses for high-cost patients; primary care accounted for
1.0%.
Health Care Expenditures
We categorized TDME using Current Procedural Technology
codes (eTable 1 in the Supplement). Total direct medical expenses include insurer costs and family costs, such as copayments, but do not include indirect costs, such as lost wages,
parking, and out-of-pocket charges. In our organization’s contract, behavioral health claims are not separated from medical claims (“carved out”) as they are in some other contracts.
We reviewed the distribution of TDME by cost per member per
month and defined the top 1.0% of patients (n = 132) with the
highest medical costs as high cost.
Demographic and Clinical Characteristics
of the Study Cohort
We compared high-cost and non–high-cost adolescents by age,
sex, and neighborhood income level. We did not have income data for individual patients but used their zip codes to
assess whether median income in the neighborhood was 200%
or more of the federal poverty level in 2012.16,17 Race and ethnicity data were not available. Our choice of clinical characteristics was opportunistic and limited to data available in a
billing database, but based on prior studies suggesting risk factors for high expenses in both children and adults, as well as a
pilot study in an academic adolescent clinic.2,8,10,14,15,18 eTable
2 in the Supplement contains a description of the clinical categorization. We used Clinical Classifications Software developed at the Agency for Healthcare Research and Quality (AHRQ)
to assign each patient to 1 of 16 mutually exclusive groups.2
For each high-cost patient, we identified the proportion of
TDME associated with each of the patient’s primary billing diagnoses. If 1 diagnosis was associated with most of the patient’s TDME, we assigned the patient to an AHRQ clinical category based on that diagnosis. Two pediatricians (S.H.G. and
L.V.) reviewed all the claims to determine what condition was
most clearly associated with a patient incurring high costs. In
19 of 132 patients, the AHRQ category was reassigned based
on clinical judgment. As an example, a patient with a congenital brain anomaly was hospitalized multiple times with pneumonia. Most of the claims were for pneumonia, and the patient was initially categorized as having a respiratory condition,
but we thought that the true cost driver was the brain anomaly
and thus changed the categorization to congenital.
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Privately Insured Adolescents’ Health Care Costs
Original Investigation Research
Figure. Percentage of Total Direct Medical Expenses Used by Health Care Service for High-Cost
vs Non–High-Cost Adolescents
Health Care Service,
No. of Patients and Mean Cost per Patient
A High-cost adolescents (n=132; $9.7 million total spending)
Inpatient (n = 90; $41 979)
Non-PCP pharmacy (n = 124; $21 648)
Non-PCP outpatient (n = 132; $13 745)
Other (n = 105; $4506)
Emergency (n = 89; $3378)
Radiology (n = 106; $2528)
Laboratory services (n = 125; $2003)
PCP outpatient (n = 122; $777)
PCP pharmacy (n = 67; $1156)
0
5
10
15
20
25
30
35
40
Overall Spending, %
Non–high-cost adolescents (n = 12 971; $31.5 million total spending)
Health Care Service,
No. of Patients and Mean Cost per Patient
B
Inpatient (n = 264; $6700)
Non-PCP pharmacy (n = 5357; $618)
Non-PCP outpatient (n = 8556; $1342)
Other (n = 2806; $723)
Emergency (n = 2273; $787)
Radiology (n = 3720; $560)
Laboratory services (n = 7493; $242)
PCP outpatient (n = 10 756; $562)
PCP pharmacy (n = 4460; $266)
0
5
10
15
20
25
30
35
40
Overall Spending, %
Statistical Analysis
We used χ2 analysis to compare all binary variables—neighborhood income level (≥200% or <200% of the federal poverty level), sex, presence of behavioral health diagnosis, obesity, chronic complex conditions (CCC) (none, 1, or >1)—as well
as calculating relative risk and 95% CIs of being in the top 1.0%
of expenses. The one continuous variable considered, mean
age distribution, was analyzed using a t test. To assess risk factors for being a high-cost patient, we used logistic regression
to obtain unadjusted and adjusted relative risk.19 Mean TDME
for each predictor was modeled using analysis of variance. Statistical analyses were performed with SAS, version 9.3 (SAS Institute Inc). Statistical significance was set at P < .05.
Results
Study Cohort
There were 13 103 adolescents in the final cohort, with a mean
(SD) age of 16.3 (2.4) years; 6764 (51.6%) were male. More than
97% lived in a zip code with median income greater than or
equal to 200% of the federal poverty level. A total of 2768 patients (21.1%) had a behavioral health diagnosis; 680 (5.2%) had
an obesity diagnosis, 1401 (10.7%) had at least 1 CCC, and 138
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Inpatient care accounts for the
greatest proportion of spending in
high-cost adolescents, whereas
specialist outpatient care represents
the greatest proportion of spending
in non–high-cost adolescents. PCP
indicates primary care provider.
(1.1%) had 2 or more CCCs. Total direct medical expenses for
the cohort were $41.2 million.
Health Care Spending
The median annual TDME per patient was $1167. High-cost patients had a median annual TDME of $52 577 compared with
$1151 for the rest of the cohort.
Spending for High-Cost Patients
The top 1.0% of adolescents with the highest medical costs accounted for 23.6% of total spending ($9.7 million) for the cohort. Inpatient care accounted for the largest single portion of
spending (38.8%) for high-cost patients, as shown in the Figure.
More than two-thirds (90 [68.2%]) of high-cost patients used inpatient hospital services. Inpatient expenses were highest for
adolescents with AHRQ categories of congenital and mental illness (Table 1). Medications accounted for the next largest percentage of expenditures (28.4%) in high-cost patients. When we
reviewed pharmaceutical costs more closely, we found that 8 orphan drugs accounted for $1.5 million of spending, 15.5% of the
TDME for the 132 high-cost adolescents and 3.6% of the TDME
for the entire cohort of 13 103 patients. This amount spent on orphan drugs was greater than all pharmacy costs for prescriptions written by PCPs for all adolescents in the entire cohort.
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Research Original Investigation
Privately Insured Adolescents’ Health Care Costs
Table 1. AHRQ Clinical Category and Annualized Expenses for High-Cost Adolescents
AHRQ Clinical Category
No. of
Patients
Overall
TDME, $a
Expense of Most
Costly Service
(%), $a
Most Costly
Services
Congenital
15
1 794 900
Inpatient
Endocrine, metabolic, and
immunity
19
1 721 600
Non-PCP pharmacy
Mental illness
22
1 239 500
Musculoskeletal
12
786 300
Hematology
3
Neoplasms
7
Injury and poisoning
Second Most
Costly Service
Expense of Second
Most Costly Service
(%), $a
941 900 (52.5)
Non-PCP outpatient
280 300 (15.6)
1 324 800 (77.0)
Non-PCP outpatient
168 600 (9.8)
Inpatient
768 100 (62.0)
Non-PCP outpatient
136 600 (11.0)
Inpatient
497 900 (63.3)
Non-PCP outpatient
210 900 (26.8)
695 800
Non-PCP pharmacy
619 600 (89.0)
Non-PCP outpatient
648 300
Non-PCP outpatient
230 200 (35.5)
Inpatient
29 900 (4.3)
192 000 (29.6)
9
585 900
Inpatient
411 600 (70.3)
Non-PCP outpatient
99 300 (17.0)
11
496 900
Inpatient
195 300 (39.3)
Non-PCP pharmacy
142 100 (28.6)
Nervous system
9
421 300
Non-PCP outpatient
155 100 (36.8)
Inpatient
Circulatory
7
381 800
Inpatient
184 100 (48.2)
Non-PCP outpatient
116 800 (30.6)
Non-PCP pharmacy
116 900 (33.6)
Digestive
Genitourinary
4
348 000
Non-PCP outpatient
176 600 (50.8)
Symptoms and ill-defined
conditions
2
188 700
Non-PCP outpatient
73 700 (39.1)
Pregnancy and childbirth
5
174 800
Inpatient
Infectious and parasitic diseases
2
160 600
Inpatient
Respiratory
3
135 400
2
99 100
132
9 878 900
Skin
Overall
92 900 (22.1)
Inpatient
61 300 (32.5)
121 900 (69.8)
Non-PCP outpatient
16 200 (9.3)
134 900 (84.0)
Non-PCP outpatient
7400 (4.6)
Inpatient
52 300 (38.7)
Non-PCP outpatient
45 700 (33.8)
Inpatient
44 500 (44.9)
Non-PCP pharmacy
43 300 (43.7)
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; PCP, primary care provider; TDME, total direct medical expense.
a
Rounded to nearest $1000.
Table 2. Characteristics of High-Cost vs Non–High-Cost Adolescents
Valuea
Characteristic
High-Cost
(n = 132)
Non–High-Cost
(n = 12 971)
Age, mean (SD), y
16.1 (2.2)
16.3 (2.4)
.23
Female sex
62 (47.0)
6277 (48.4)
.79
3 (2.3)
292 (2.3)
.77
Obesity diagnosis
18 (13.6)
662 (5.1)
<.001
Behavioral health diagnosis
78 (59.1)
2690 (20.7)
<.001
0
59 (44.7)
11643 (89.8)
1
49 (37.1)
1214 (9.4)
≥2
24 (18.2)
114 (0.9)
Median income level by zip code <200% FPL
P Value
Complex chronic condition, No.
Primary care services accounted for 1.0% of spending for
high-cost adolescents. Although 92.4% of high-cost patients
had at least 1 visit with a PCP, the mean cost per patient was
$777. Eighty-nine high-cost adolescents (67.4%) had at least 1
emergency department visit, which accounted for 3.1% of
TDME. One hundred six high-cost adolescents (80.3%) had at
least 1 radiology study and 94.7% had at least 1 laboratory study
ordered. Radiology and laboratory services accounted for 2.8%
and 2.6%, respectively, of TDME.
Abbreviation: FPL, federal poverty
level.
<.001
a
Data are presented as number
(percentage) of patients unless
otherwise indicated.
at least 1 PCP visit, and 4460 (34.4%) received at least 1 prescription from a PCP. Few (264 [2.0%]) non–high-cost patients were hospitalized, accounting for 5.6% of TDME; 2273
(17.5%) had at least 1 emergency department visit, accounting
for 5.7% of TDME; 3720 (28.7%) had at least 1 radiology service, accounting for 6.6% of TDME; and 7493 (57.8%) had at least
1 laboratory test, accounting for 5.7% of TDME. A total of 2492
(19.2%) of these adolescents had no expenses for the year.
Characteristics of High-Cost Adolescents
Spending in Non–High-Cost Adolescents
For non–high-cost adolescents, 47.0% of TDME was for nonPCP specialist outpatient services and prescriptions; 8556 of
these adolescents (66.0%) were seen by a non-PCP specialist.
Primary care provider outpatient services and PCP-derived
pharmacy costs represented 22.9% of TDME, as shown in the
Figure. Most non–high-cost adolescents (10 756 [82.9%]) had
4/7
Age, sex, and neighborhood income level were not significantly different between high-cost and non–high-cost patients
in this cohort, as shown in Table 2. High-cost patients were more
than twice as likely to have a behavioral health diagnosis, be
obese, or have 1 or more CCCs compared with non–high-cost patients. Many high-cost patients (44.7%) did not have a CCC. Those
without a CCC fit largely into 2 categories: those with chronic con-
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Privately Insured Adolescents’ Health Care Costs
Original Investigation Research
Table 3. Relative Risk of Being a High-Cost Adolescent Patient
Predictor
Median Annualized
TDME (IQR), $a
Relative Risk (95% CI)
Adjusted Modelb
Unadjusted Model
Age, y
13-15
1198 (554-2754)
1.0 [Reference]
1.0 [Reference]
16-18
1291 (557-3065)
1.0 (0.7-1.5)
1.1 (0.8-1.6)
19-21
905 (252-2346)
0.8 (0.5-1.3)
1.0 (0.6-1.6)
Sex
Male
1032 (419-2526)
1.0 [Reference]
1.0 [Reference]
Female
1329 (594-3061)
0.9 (0.7-1.3)
0.9 (0.7-1.3)
Median income level by zip code
≥200% FPL
833 (308-1807)
1.0 [Reference]
1.0 [Reference]
<200% FPL
1176 (506-2819)
1.0 (0.4-2.7)
1.4 (0.5-3.8)
No
1144 (486-2753)
1.0 [Reference]
1.0 [Reference]
Yes
1669 (823-3835)
2.9 (1.8-4.7)
2.0 (1.3-3.0)
Obesity diagnosis
Behavioral health diagnosis
No
908 (397-2012)
1.0 [Reference]
1.0 [Reference]
Yes
2969 (1612-5926)
5.4 (3.9-7.5)
3.6 (2.6-5.1)
0
1037 (447-2441)
1.0 [Reference]
1.0 [Reference]
1
3027 (1476-6441)
≥2
8252 (3617-23 684)
Complex chronic condition, No.
7.7 (5.5-110.8)
6.5 (4.7-9.0)
34.5 (19.9-59.9)
23.5 (14.2-39.1)
ditions not included in Feudtner et al’s20 categorization scheme
(eg, mental health disorders, hemophilia, short stature), and
those with acute or time-limited but expensive conditions ranging from complex fractures and surgical emergencies to pregnancy. Table 3 shows the results of a multivariable model of predictors of being a high-cost adolescent. After adjustment for age,
sex, and median income by zip code, having 2 or more CCCs conferred a 23.5-fold risk of being a high-cost patient (95% CI, 14.239.1); having 1 CCC, a 6.5-fold risk (95% CI, 4.7-9.0); having a behavioral health diagnosis, a 3.6-fold risk (95% CI, 2.6-5.1); and
being obese, a 2.0-fold risk (95% CI, 1.3-3.0).
The AHRQ clinical categories associated with the most TDME
among the high-cost adolescent cohort were congenital ($1.8 million); endocrine, metabolic, and immunity ($1.7 million); and
mental illness ($1.2 million) (Table 1). The most common conditions within the congenital category were congenital heart disease, Down syndrome, and spina bifida. Inpatient hospitalizations were the greatest driver of expense within the congenital
category (Table 1). The next most expensive AHRQ category was
endocrine, metabolic, and immunity, with the most common
specific condition being short stature (n = 10). Pharmaceutical
costs within this category accounted for $1.3 million, 77.0% of
the total cost for this category and more than the total amount
spent on the next most expensive AHRQ category, mental illness, with total expenses of $1.2 million. Mental illness was the
category with the largest number of patients in the high-cost cohort (n = 22); the most common specific condition among these
patients was mood disorders (n = 14). The most expensive AHRQ
clinical category per individual patient was hematology, with an
average TDME of more than $230 000 per patient (Table 1). Most
(89.1%) of these costs were pharmacy costs.
jamapediatrics.com
Abbreviations: FPL, federal poverty
level; IQR, interquartile range;
TDME, total direct medical expense.
a
IQR is 25th and 75th percentiles.
b
Adjusted for all covariates listed.
Discussion
In this analysis of TDMEs of a large population of privately insured adolescent patients, we found that the 1.0% of patients
who incurred the highest charges accounted for almost onefourth of costs, a skewed distribution similar to other pediatric studies of both privately and publicly insured patients.10,12-14
The source of costs varied widely by clinical condition, with
hospitalization and pharmacy costs driving expense for the
highest-cost adolescents. Orphan drugs in particular contributed disproportionately to these costs. Having 2 or more CCCs
was the strongest predictor of being a high-cost patient, although almost half of the high-cost patients in our cohort did
not have a CCC.
Understanding predictors of high-cost health care is increasingly important owing to shifts in insurance benefit design that increase the cost-sharing burden to families. Stiles
et al recently outlined the need for “predictive models to identify children with complex medical conditions whose care may
be ‘impactable’ by improving care quality and reducing
costs.”21(p204) Increasing quality and decreasing expense for
adolescents will require tailored approaches. The skewed distribution of costs makes the idea of care coordination for a small
number of adolescents attractive, but in many cases, high costs
may not be modifiable unless pharmacy costs can be decreased. Pediatric populations may be particularly vulnerable to high pharmacy costs because of orphan drugs. A drug
is eligible for orphan drug designation from the US Food and
Drug Administration if it is intended to treat a condition that
affects fewer than 200 000 people in the United States or there
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Research Original Investigation
Privately Insured Adolescents’ Health Care Costs
is “no reasonable expectation that the cost of developing and
making available a drug for the disease or condition will be recovered from sales of the drug.”22 These drugs have benefited children with rare disorders but account for a disproportionate amount of pharmacy costs. As of July 2014, orphan
drugs are specifically excluded from the 340B discount drug
pricing program for children’s hospitals and safety-net hospitals, so public policy or private insurer negotiation with individual pharmaceutical companies is potentially the only means
of lowering these expenses for pediatric patients.23
By contrast, patients with expenses incurred by frequent
hospitalization and non-PCP outpatient visits could be modifiable via care coordination. Patients with congenital conditions and mental illness had the highest hospitalization costs
in our cohort. Patients with congenital conditions also had the
highest non-PCP outpatient costs, followed by those with neoplasms. Our finding that primary care services accounted for
only a tiny fraction of the TDME of the highest-cost adolescents is consistent with a recent study demonstrating that primary care services represented only 2.2% of spending for Medicaid-insured medically complex pediatric patients.11 Our data
suggest that PCPs do not currently have a large role in providing care coordination for the highest-cost adolescents (or at
least are not reimbursed for it), but it is unclear whether PCP
coordination would reduce expenses in patients with rare diseases using orphan drugs or patients without CCC who experience acute injury, illness, or pregnancy.
The fact that mental health conditions were prevalent
among high-cost adolescents suggests that mental health care
professionals must be included in case management models
to reduce medical expenses. There is significant unmet need
for care coordination for children with behavioral health
diagnoses.24 Some studies suggest that intensive case management improves clinical outcomes and reduces hospitalization for adults with severe mental illness, and some smaller
studies demonstrate cost-effectiveness of integrated behavioral health care.25-27 New care models that integrate behavioral health care professionals into pediatric primary care
practices have the potential to demonstrate significant costeffectiveness if hospitalizations can be reduced.
Our data suggest that some strategies for cost reduction
may yield only low savings in practices with high numbers of
privately insured adolescents, such as initiatives centered on
primary care prescribing, which accounted for the lowest
percentage of spending for high-cost and non–high-cost
patients. Relatively little TDME in this cohort of adolescents
was related to the use of emergency services, suggesting that
efforts to reduce emergency department use may also yield
only low savings for some patient populations. This finding
stands in contrast to a recent study showing frequent emergency department use in publicly insured children and adolescents, although adolescents used emergency services significantly less than did younger children. 28 Because the
patterns of health care use appear to be significantly different
between younger children and adolescents and between privately and publicly insured adolescents, investigators should
consider stratified or separate analyses for these groups.
These kinds of analyses will be vital for health care profes6/7
sionals in pediatric accountable care models. It is also worth
noting that for overall cost containment, adolescent health
care expenses are dwarfed by those of neonates and the
elderly in the last year of life.13
This study had several limitations. The cohort was limited to adolescents in pediatric primary care practices who
were largely well. They live in a geographic area with access
to a high concentration of pediatric subspecialists, including
a large freestanding children’s hospital and many academic
institutions with pediatric inpatient and specialty programs,
which may increase costs and may not be generalizable to
other areas. It is also probable that children with special
health care needs and CCCs are underrepresented because
their conditions may make them eligible for Medicaid. The
data were derived from a billing database with limited demographic and clinical information, so we had little information
about variables that are important determinants of health.
For example, only 5.2% of our cohort had a claim including a
diagnosis of obesity. Since the proportion of adolescents
known to be obese is substantially higher than that in our
study (9.9% in Massachusetts in 2011),29 it is possible that
our use of claims data underestimated the true rate of obesity
in our population, although obesity is more prevalent in lowincome families. Supplementing administrative data with
clinical data in future studies may be a way to reduce such
potential misclassifications. Another limitation is the identification of youth with special health care needs using coding
data when there is no universal definition of special needs.30
We chose to use the definition of CCCs used by Feudtner et al
because this model has demonstrated utility in predicting
morbidity and mortality and because we wanted to provide a
model that was clinically relevant as well as cost informed.20,31,32 For future studies of adolescents’ health care
use and costs, investigators could consider a “CCC+” model
that would add hemophilia, pregnancy, and mental health
disorders to the categories proposed by Feudtner et al.
Future studies could take several directions. The group of
adolescents with CCCs who were not in the highest TDME
group warrants further study in searching for cost reduction
strategies. Interestingly, while adolescents with 2 or more CCCs
are overrepresented in the top 1.0% of the cohort, many of these
young people are actually not in the top 1.0% of spending. We
stand to learn from what is going well in terms of cost containment for these complex patients. Another next step will
be to study longer-term persistence of these health care costs.
Many adolescents’ conditions are self-limited by their nature, such as acute injuries, pregnancy, and short stature.
Conclusions
There is an urgent need for health care professionals to understand and proactively identify high-cost patients for clinical interventions. For privately insured adolescents, potential strategies for cost reduction include care coordination for
those with CCCs and mental health diagnoses, integrated behavioral health care, and negotiation to reduce pharmacy costs,
especially for orphan drugs.
JAMA Pediatrics Published online October 5, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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jamapediatrics.com
Privately Insured Adolescents’ Health Care Costs
ARTICLE INFORMATION
Accepted for Publication: August 4, 2015.
Published Online: October 5, 2015.
doi:10.1001/jamapediatrics.2015.2682.
Author Contributions: Dr Gray had full access to all
the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data
analysis.
Study concept and design: Gray, Emans, Woods,
Berry, Vernacchio.
Acquisition, analysis, or interpretation of data: Gray,
Trudell, Emans, Vernacchio.
Drafting of manuscript: Gray, Vernacchio.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Trudell, Vernacchio.
Study supervision: Gray, Emans, Woods, Berry,
Vernacchio.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was partly supported
by Leadership Education in Adolescent Health
Training grant T71 MC00009 from the Maternal
and Child Health Bureau, Health Resources and
Services Administration (Drs Emans and Woods)
and grant R21 HS023092 from the Agency for
Healthcare Research and Quality (Dr Berry).
Role of the Funder/Sponsor: The funding source
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Additional Contributions: Barry Zallen, MD, Ann
Suny, BA, MBA, and Nora Boukus, MA, Children’s
Hospital Integrated Care Organization, and Urmi
Bhaumik, MBBS, MS, ScD, Division of Adolescent
and Young Adult Medicine and Office of
Community Health consulted with us on the design
of the pilot project that served as the basis of this
investigation. They were not compensated for their
contribution.
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(Reprinted) JAMA Pediatrics Published online October 5, 2015
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