Pediatric patients with both autism spectrum disorder and medical complexity may account for 5.4% of total U.S. pediatric health care expenditures despite representing only 0.6% of the pediatric population, according to a recent study. 

In the study, published in Pediatrics, investigators examined the overlap between autism spectrum disorder (ASD) and medical complexity (MC) among U.S. pediatric patients using national data sets to estimate prevalence and health care expenditures. They analyzed data from the 2017 to 2022 National Survey of Children’s Health (NSCH) and the 2010 to 2021 Medical Expenditure Panel Survey. MC refers to pediatric patients with multiple or severe chronic health conditions who require specialized care across multiple systems. Two algorithms were applied to define MC: the Children with Special Healthcare Needs screener (CMC-S) and the Yu et al. method (CMC-Yu). The latter employed stricter criteria. Using these definitions, the prevalence of MC among pediatric patients with ASD was estimated at 59.3% (CMC-S) and 17.6% (CMC-Yu).

The findings showed that among pediatric patients with ASD in the 2021 to 2022 NSCH dataset (n = 103,748), the prevalence of MC was 59.3% (95% confidence interval [CI] = 55.6%–62.8%) using the CMC-S algorithm and 17.6% (95% CI = 14.4%–21.2%) using CMC-Yu. Among all pediatric patients who had MC, 41% had ASD, regardless of the classification method. In the MEPS data set (n = 55,637), pediatric patients with ASD and MC demonstrated significantly greater health care expenditures compared with either pediatric patients with ASD without MC or non-ASD MC. Median annual health care expenditures were highest among pediatric patients with ASD and MC ($5,510), followed by non-ASD MC ($3,842), those with ASD but without MC ($1,372), and those with neither condition ($432). This group accounted for 5.4% of total U.S. pediatric health care expenditures despite representing only 0.6% of the pediatric population.

Lead study author Philip H. Smith, PhD, of the A.J. Drexel Autism Institute, and colleagues analyzed the overlap between ASD and MC and found that, despite significant co-occurrence, these groups were often treated separately in health care services, policy, and research. This overlap in ASD and MC highlighted the need for integrated health care services to manage both conditions efficiently. The study also examined Medicaid waiver programs and care models and identified gaps in service utilization and health care coordination that may have impacted access to integrated care.

Full disclosures can be found in the published study.