ADHD: INCREASED COSTS FOR PATIENTS AND THEIR FAMILIES
Study from USA: from ADHD Research Newsletter by David Rabiner
Although there is an extensive body of research examining the behavioral, academic, and social outcomes associated with ADHD, little work has examined the financial burden associated with the disorder. In studies where the costs of ADHD have been examined, higher medical costs have been found. These costs have been linked to increased hospital admissions and emergency room services, perhaps because accident rates are higher among children and teens with ADHD. Information about increased costs for other family members is not known, although it is reasonable to speculate that costs may be higher because of the increased stress that may accompany raising a child with a chronic medical condition like ADHD.
A study published in a recent issue of the Journal of the American Academy of Child and Adolescent Psychiatry (Swensen, A., et al., (2003). Attention Deficit/Hyperactivity Disorder: Increased costs for patients and their families, JAACAP, 42, 1415-1423) provides important new data on this issue. The goal of this study was to assess the economic burden of childhood ADHD on families and employers. Specifically, the authors sought to estimate the total medical care costs of children/teens with ADHD, as well as medical care costs of their family members.
To estimate these costs, the authors examined medical and pharmaceutical claims data for more than 100,000 beneficiaries of a large Fortune 100 company. (Note: All identifying information was removed so that patient/employee confidentiality was protected). Within this large sample, individuals under 18 were classified as an ADHD patient if they had one or more ADHD medical or disability claims during the 3-year period for which claims data was available. Confirming the accuracy of the diagnosis was not possible, however.
Comparison subjects who were matched with ADHD patients on age, gender, state of residence, and employment status of the parent/policy holder were also identified. By comparing the medical claims history for children/teens with ADHD and their family members with the claims history of comparison subjects and their family members, the medical costs associated with ADHD for families could be ascertained. Medical claims data were analyzed for a single 12-month period and were divided into claims for the treatment of ADHD and claims for any other medical treatment. Over 1000 patients with ADHD and an equal number of matched controls were included in the cost comparisons reported below.
RESULTS
Because ADHD often occurs along with other psychiatric conditions, the authors first examined how often children with ADHD and their family members were treated for psychiatric disorders besides ADHD. Overall, patients with ADHD were treated for other mental disorders (e.g. depression, conduct disorder, and oppositional defiant disorder) 5 times more frequently than their matched controls - i.e., 28.7% vs. 5.9%.
The high rate of comorbid disorders in patients with ADHD replicates finding from many prior studies. Results like these highlight the need for comprehensive assessment and treatment planning so that other difficulties in addition to ADHD are clearly identified and addressed in a child's treatment.
Analogous results were found for the family members of ADHD patients, i.e., rates of psychiatric disorders were higher among family members of the ADHD patients than among family members of controls. The magnitude of the difference, however, was smaller than what was found for patients themselves. Depression was the disorder that showed the greatest disparity between family members of ADHD patients, i.e., 9%, and comparison subjects, i.e., 4%.
MEDICAL UTILIZATION COSTS
Patients with ADHD had 2.6 times more medical claims during the year than the non-ADHD comparison subjects. Of note is that this difference could not be attributed to claims for ADHD treatment specifically, which accounted for only 24% of total claims during the year.
A concerning finding is that only 53% of patients with ADHD received ADHD treatment from a medical professional or allied health professional (e.g. psychologist, social worker) during the year. Only 43% received treatment from a psychiatrist and 41% did not fill a prescription for ADHD medication. Information on treatments that may have been obtained outside of the traditional health care system, and for which claims would not have been filed, was not available.
The annual expenditures for patients with ADHD were substantially higher than for comparison subjects, i.e., $1,574 vs. $541, and approximately 80% of the higher costs were for reasons other than ADHD treatment. The authors suggest that "...the hidden costs of the manifestations of ADHD and the accompanying comorbidities of patients with ADHD were associated with the economic burden of the disease."
COSTS FOR FAMILY MEMBERS
The ADHD family member sample consisted of 3,404 individuals, and the non-ADHD family member sample included 3,933 individuals. Family members of ADHD patients had 60% more medical claims and about twice as many were treated for a psychiatric disorder.
Direct medical care costs per family member was twice as high, i.e., $2060 vs. $1,026. Thus, in combination with the greater costs to the ADHD patient him/herself, the average additional annual medical costs to a 4-person family where one child had ADHD would have been over $4,000 during the year. Although a portion of these additional costs were covered by insurance reimbursements, the additional co-payments required would have resulted in substantial costs to the families as well.
Indirect costs - i.e., disability and absenteeism - were also greater in families with an ADHD patient, i.e., $668 vs. $414.
SUMMARY AND IMPLICATIONS
Results from this study document a significant economic burden to families who have a child with ADHD. Medical utilization and costs are substantially and treatment directly related to the disorder explains only a portion of increased costs. In addition to increased costs for the child with ADHD, medical costs for family members were also substantially higher. In fact, the increased costs to the patient and family members appear to be thousands of dollars per year. Although insurance would have covered much of this cost, co-pay requirements for families would have been substantial as well, particularly when one considers that these additional costs are likely to recur each year.
In addition to the economic data, it is noteworthy that only 53% of patients with ADHD received ADHD treatment during the year a physician or allied health professional, e.g., psychologist, social worker. In addition, over 40% of patients had no prescriptions for ADHD medication filled during the year.
It is possible that some patients received care for ADHD that was not coded as an ADHD treatment visit, or received ADHD treatment outside of the traditional medical system. Nonetheless, these findings raise important questions about the type and quality of care that children with ADHD received. These data imply that many children were not receiving care that was consistent with recently published treatment guidelines from the American Academy of Pediatrics.
The authors note several limitations to their study. First, they emphasize that their sample is not representative of the entire population, as many families have different insurance coverage from the families in their sample or have no insurance at all. The extent to which the current findings would generalize to these other circumstances is unknown.
Second, because this study relied on insurance claims data, the findings are subject to the usual limitations of such data including the possibilities of inaccurate diagnoses, coding inaccuracies on claims forms, and missing data. It is unlikely, however, that such errors would have substantially influenced the results obtained.
Third, the authors acknowledge that they were not able examine the costs of ADHD beyond medical care. Thus, there may be substantial additional expenses for families who have a child with ADHD that are not reflected in this report.
Finally, it is important to emphasize that this study provides no information on the reasons why medical costs in patients with ADHD and their family members were so much higher. Although these costs may be directly related to, or caused by, ADHD itself, e.g., children with ADHD are more accident prone and this results in higher medical costs; the stress that parents experience caring for the child with ADHD has adverse impacts on their own health, no direct information on this issue is provided. Thus, the reasons why ADHD is associated with higher medical costs in children and their family members would be an important question to pursue in future research.