Design and Method
Study population
The study population comprised all Medicaid-eligible youth aged 3 to 17 in a selected subset of states for the years 2001-2010. Enrollee age, for the purposes of inclusion in analyses, was computed as of July 1 of each year. Eleven months (not necessarily consecutive) of Medicaid eligibility in the year were required for inclusion in the analytic population. The twenty states selected for inclusion in the study were those that we and others found, in internal analyses as well as in published work, to provide relatively complete diagnosis and treatment detail. The overall study population meeting the age, eligibility, and state inclusion criteria ranged from 5.2m in 2001 to 8.2m in 2010.
Data sources
The primary data source for this study consisted of Medicaid enrollment, claims, and prescription drug fill data from the Medicaid Analytic Extract (MAX). The MAX data provide a set of research files constructed from regular mandated data submissions from the state Medicaid programs and compiled and processed by the Centers for Medicare and Medicaid Services (CMS). Enrollment data include information on beneficiary characteristics such as age, sex, and race/ethnicity; as well as Medicaid eligibility; managed care participation; and other details that affect how care is organized and paid for. Claims are provided separately for inpatient, long-term care, and other (primarily outpatient) services, and include details on diagnoses received and services delivered. A prescription drug file provides records for each filled prescription, allowing researchers to identify which medications were received, when the prescriptions were filled, how much of the drug was provided, and for how long. The prescription drug records were linked to the First Data Bank National Drug Data File (NDDF), which provides the means to look up drug details using the National Drug Codes (NDCs) provided in the MAX data. Prescription medications were extracted from the MAX data by their generic names.
Database construction and analysis
Our preliminary MAX data analyses included 44 states and the District of Columbia. We then identified a subset of 20 states that in 2009 either (a) had predominantly fee-for-service (FFS) youth Medicaid populations or (b) had been identified as having relatively complete and usable
managed care encounter data for that population.1 Key variables included in these data sets were: sociodemographic characteristics (age, sex, race/ethnicity), month-by-month eligibility data, diagnoses recorded, services received, and prescriptions filled. An eligibility threshold, requiring a minimum of 11 Medicaid-eligible months in the year, was also established following preliminary analyses of the MAX enrollment data. Only data for youth age three to under 18 were included in analyses. The few youth with dual Medicaid-Medicare eligibility were excluded from analyses because records from Medicare, which is the first payer for many services, were not observable.
Enrollees were assigned to one of several basis-of-eligibility (BoE) groups following examination of their eligibility records: SSI/Disability, Foster care, and Other. Analyses were stratified or subset by this grouping variable. We used each enrollee’s last observed BoE category in each year to assign her/him an overall status for the year. This was necessary in order to establish mutually exclusive eligibility categories. Preliminary analyses revealed substantial consistency throughout the year for the focal SSI/Disability group, suggesting that our method of assigning BoE categories on the basis of the last observation of the year did not distort these enrollees’ eligibility histories.2 The mappings from MAX BoE categories to our three groupings are details in Appendix A. Where the tables, charts, or text below refer to the full population or to subpopulations (e.g., SSI/Disability), it is implied that enrollees also met the age, eligibility, and state inclusion criteria.
Presence of ADHD and other diagnoses was identified using the multiple diagnosis fields in the MAX claims files, excluding the long-term care claims. A threshold of one or more inpatient claims, or two or more outpatient or other non-inpatient claims on different dates, was used to establish the presence of the following conditions for each enrollee for each year of analysis (via ICD-9-CM codes):
- ADHD (both alone and complicated by other conditions)
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1 See https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Computer‐Data‐and‐Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB_15_AssessingUsability.pdf and http://mathematicampr.com/publications/pdfs/health/MAX_IB14.pdf
2 We found that 96% of enrollees assigned to the SSI/Disability group on the basis of their last observation of the year had no other BoE at any point earlier in the year.
- Conduct disorder
- Emotional disturbances
- Oppositional defiant disorder
- Mood disorders (Depression)
- Mood disorders (Bipolar disorders)
- Anxiety disorders
- Autism spectrum disorders
- Intellectual disorders
- Speech and language disorders
- Hearing disorders (control)
- Learning disorders (control)
Two subcategories of ADHD complicated by (1) any of the non-control conditions and (2) an externalizing disorder (conduct disorder or oppositional defiant disorder) were also identified. Cerebral palsy and asthma were identified as control conditions. The ICD-9-CM codes used to establish diagnoses are listed in Appendix B.
Pharmacological treatments were identified via generic drug names associated with filled prescriptions in the linked MAX/NDDF data and reported using the following categories of medications: ADHD medications, antipsychotic medications, antidepressants, anxiolytic/hypnotic medications, and mood stabilizers. The generic drug names for each category are listed in Appendix C. Non-pharmacological treatments were identified via procedure codes recorded in the MAX claims (using Current Procedural Terminology [CPT] codes in Appendix D).
Once enrollees’ eligibility, sociodemographic characteristics, diagnoses, prescriptions, and services were identified, analyses were performed to track diagnosis and treatment trends over the 2001-2010 period.
Project conducted by:
Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and
Outcomes, and Center for Education and Research on Mental Health Therapeutics
Institute for Health, Health Care Policy, and Aging Research
Rutgers University
Part A: Study categorizations (left) of MAX BoE groupings (right)
Current Study | CMS |
N/A | NOT ELIGIBLE |
Other | AGED, CASH |
SSI/Disability | BLIND/DISABLED, CASH |
Other | CHILD (NOT CHILD OF UNEMPLOYED ADULT, NOT FOSTER CARE CHILD), ELIGIBLE UNDER SECTION 1931 OF THE ACT |
Other | ADULT (NOT BASED ON UNEMPLOYMENT STATUS), ELIGIBLE UNDER SECTION 1931 OF THE ACT |
Other | CHILD OF UNEMPLOYED ADULT, ELIGIBLE UNDER SECTION 1931 OF THE ACT |
Other | UNEMPLOYED ADULT, ELIGIBLE UNDER SECTION 1931 OF THE ACT |
Other | AGED, MN |
SSI/Disability | BLIND/DISABLED, MN |
Other | CHILD, MN (FORMERLY AFDC CHILD, MN) |
Other | ADULT, MN (FORMERLY AFDC ADULT, MN) |
Other | AGED, POVERTY |
SSI/Disability | BLIND/DISABLED, POVERTY |
Other | CHILD, POVERTY (INCLUDES MEDICAID EXPANSION CHIP CHILDREN) |
Other | ADULT, POVERTY |
Other | INDIVIDUAL COVERED UNDER THE BREAST AND CERVICAL CANCER PREVENTION ACT OF 2000, POVERTY |
Other | OTHER AGED |
SSI/Disability | OTHER BLIND/DISABLED |
Other | OTHER CHILD |
Other | OTHER ADULT |
Foster Care | FOSTER CARE CHILD |
Other | AGED, SECTION 1115 DEMONSTRATION EXPANSION |
SSI/Disability | DISABLED, SECTION 1115 DEMONSTRATION EXPANSION |
Other | CHILD, SECTION 1115 DEMONSTRATION EXPANSION |
Other | ADULT, SECTION 1115 DEMONSTRATION EXPANSION |
Other | UNKNOWN ELIGIBILITY |
Part B: Diagnostic groupings (ICD-9-CM)
ADHD/Attention deficit hyperactivity disorder | |
314.00 | Attention deficit disorder, without mention of hyperactivity |
314.01 | Attention deficit disorder, with hyperactivity |
314.2 | Hyperkinetic conduct disorder |
314.8 | Other specified manifestations of hyperkinetic syndrome |
314.9 | Unspecified hyperkinetic syndrome |
Conduct disorder | |
312.x | Disturbance of conduct, not elsewhere classified |
Emotional disturbances | |
313.x | Disturbance of emotions specific to childhood and adolescence |
Oppositional defiant disorder | |
313.81 | Oppositional defiant disorder |
Mood disorders (Depression) | |
296.2x | Episodic mood disorder (Major depressive disorder) |
296.3x | Episodic mood disorder (Major depressive disorder) |
296.9x | Other and unspecified episodic mood disorder |
298.0 | Depressive type psychosis |
300.4 | Dysthymic disorder |
301.12 | Chronic depressive personality disorder |
309.1 | Prolonged depressive reaction |
311 | Depressive disorder, not elsewhere classified |
Mood disorders (Bipolar disorders) | |
296.0x | Bipolar I disorder, single manic episode |
296.1x | Manic disorder, recurrent episode |
296.4x | Bipolar I disorder, most recent episode (or current) manic |
296.5x | Bipolar I disorder, most recent episode (or current) depressed |
296.6x | Bipolar I disorder, most recent episode (or current) mixed |
296.7x | Bipolar I disorder, most recent episode (or current) unspecified |
296.8x | Other and unspecified bipolar disorders |
301.13 | Cyclothymic disorder |
Anxiety disorders | |
293.84 | Anxiety disorder in conditions classified elsewhere |
300.00 | Anxiety state, unspecified |
300.02 | Generalized anxiety disorder |
300.09 | Other anxiety states |
309.21 | Separation anxiety disorder |
309.24 | Adjustment disorder with anxiety |
309.28 | Adjustment disorder with mixed anxiety and depressed mood |
313.0 | Overanxious disorder |
Autism spectrum disorders | |
299.00 | Autistic disorder, current or active state |
299.01 | Autistic disorder, residual state |
299.80 | Other specified pervasive developmental disorders, current or active state |
299.81 | Other specified pervasive developmental disorders, residual state |
299.90 | Unspecified pervasive developmental disorder, current or active state |
299.91 | Unspecified pervasive developmental disorder, residual state |
Intellectual disorders | |
317 | Mild mental retardation |
318.0 | Moderate mental retardation |
318.1 | Severe mental retardation |
318.2 | Profound mental retardation |
319 | Unspecified mental retardation |
Speech and language disorders | |
315.31 | Expressive language disorder |
315.32 | Mixed receptive-expressive language disorder |
315.34 | Speech and language developmental delay due to hearing loss |
315.35 | Childhood onset fluency disorder |
315.39 | Other developmental speech or language disorder |
438.10 | Speech and language deficit, unspecified |
438.19 | Other speech and language deficits |
784.59 | Other speech disturbance |
Hearing disorders | |
380.xx | Disorders of the external ear |
381.xx | Non suppurative otitis media and Eustachian disorder |
382.xx | Suppurative and unspecified otitis media |
384.xx | Other disorders of the tympanic membrane |
385.xx | Other disorders of the middle ear and mastoid |
387.x | Otosclerosis |
388.xx | Other disorders of the ear |
389.xx | Hearing loss |
744.0x | Anomaly of ear causing impairment of hearing |
Learning disorders | |
313.83 | Academic underachievement disorder |
315.00 | Reading disorder, unspecified |
315.01 | Alexia |
315.02 | Developmental dyslexia |
315.09 | Other specific reading disorder |
315.1 | Mathematics disorder |
315.2 | Other specific learning difficulties |
315.8 | Other specified delays in development |
315.9 | Unspecified delay in development |
784.61 | Alexia and dyslexia |
Cerebral palsy - control condition | |
342.00 | Flaccid hemiplegia, affecting unspecified side |
342.01 | Flaccid hemiplegia, affecting dominant side |
342.02 | Flaccid hemiplegia, affecting nondominant side |
342.10 | Spastic hemiplegia, affecting unspecified side |
342.11 | Spastic hemiplegia, affecting dominant side |
342.12 | Spastic hemiplegia, affecting nondominant side |
342.80 | Other specified hemiplegia, affecting unspecified side |
342.81 | Other specified hemiplegia, affecting dominant side |
342.82 | Other specified hemiplegia, affecting nondominant side |
342.90 | Unspecified hemiplegia, affecting unspecified side |
342.91 | Unspecified hemiplegia, affecting dominant side |
342.92 | Unspecified hemiplegia, affecting nondominant side |
343.0 | Infantile cerebral palsy, diplegic |
343.1 | Infantile cerebral palsy, hemiplegic |
343.2 | Infantile cerebral palsy, quadriplegic |
343.3 | Infantile cerebral palsy, monoplegic |
343.4 | Infantile hemiplegia |
343.8 | Other specified infantile cerebral palsy |
343.9 | Infantile cerebral palsy unspecified |
348.1 | Anoxic brain damage |
768.5 | Severe birth asphyxia |
768.70 | Hypoxic-ischemic encephalopathy, unspecified |
768.71 | Mild hypoxic-ischemic encephalopathy |
768.72 | Moderate hypoxic-ischemic encephalopathy |
768.73 | Severe hypoxic-ischemic encephalopathy |
Asthma - control condition | |
493.00 | Extrinsic asthma, unspecified |
493.01 | Extrinsic asthma, with status asthmaticus |
493.02 | Extrinsic asthma, with (acute) exacerbation |
493.10 | Intrinsic asthma, unspecified |
493.11 | intrinsic asthma, with status asthmaticus |
493.12 | Intrinsic asthma, with (acute) exacerbation |
493.20 | Chronic obstructive asthma, unspecified |
493.21 | Chronic obstructive asthma, with status asthmaticus |
493.22 | Chronic obstructive asthma, with (acute) exacerbation |
493.82 | Cough variant asthma |
493.90 | Asthma, unspecified |
493.91 | Asthma, unspecified type with status asthmaticus |
493.92 | Asthma, unspecified with (acute) exacerbation |
Part C: Medication groupings, using generic names
ADHD medications
amphetamine, dextroamphetamine, dexmethylphenidate, lisdexamfetamine, methamphetamine, methylphenidate, modafinil, atomoxetine, clonidine, guanfacine, bupropion, imipramine, nortriptyline, desipramine
Antipsychotic medications
aripiprazole, asenapine, benperidol, chlorpromazine, clopenthixol, clotiapine, clozapine, droperidol, flupenthixol, fluphenazine, fluspirilene, haloperidol, iloperidone, levomepromazine, loxapine, lurasidone, mesoridazine, molindone, olanzapine, paliperidone, pericyazine, perphenazine, perphenazine, pimozide, pipotiazine, promazine, quetiapine, risperidone, thioridazine, thiothixene, trifluoperazine, triflupromazine, zuclopenthixol, and combined agents amitriptyline/perphenazine and olanzapine/fluoxetine
Antidepressants
amitriptyline, bupropion, citalopram, clomipramine, desipramine, desvenlafaxine, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, isocarboxazid, levomilnacipram, milnacipram, mirtazapine, nortriptyline, paroxetine, phenelzine, selegiline, sertraline, tranylcypromine, trazadone, trimipramine, venlafaxine, and combined agents amitriptyline/perphenazine and chlordiazepoxide/amitriptyline
Anxiolytic/hypnotic medications
alprazolam, atenolol, bromazepam, buspirone, chlordiazepoxide, clonazepam, clorazepate, diazepam, flurazepam, lorazepam, oxazepam, pregabalin, propranolol, temazepam, triazolam, and combined agent chlordiazepoxide/amitriptyline
Mood stabilizers
carbamazepine, gabapentin, lamotrigine, lithium, oxcarbazepine, topiramate, valproic acid/valproate/divalproex, zonisamide
Part D: Non-pharmacological treatments (Current Procedural Terminology, CPT)*
Code | Description |
90801 | Psychiatric Diagnostic Interview Examination |
90802 | Interactive Psychiatric Diagnostic Interview Examination |
90820 | Interactive Medical Psychiatric Diagnostic Interview Examination |
90804 | Office/OP Insight, Beh. Mod., or Supportive Psychotherapy, 20‐30 min. |
90805 | Office/OP Insight, Beh. Mod., or Supportive Psychotherapy, 20‐30 min. (w/eval. and mgmt.) |
90806 | Office/OP Insight, Beh. Mod., or Supportive Psychotherapy, 45‐50 min. |
90807 | Office/OP Insight, Beh. Mod., or Supportive Psychotherapy, 45‐50 min. (w/eval. and mgmt.) |
90808 | Office/OP Insight, Beh. Mod., or Supportive Psychotherapy, 75‐80 min. |
90809 | Office/OP Insight, Beh. Mod., or Supportive Psychotherapy, 75‐80 min. (w/eval. and mgmt.) |
90810 | Office/OP Interactive Psychotherapy, 20‐30 min. |
90811 | Office/OP Interactive Psychotherapy, 20‐30 min. (w/eval. and mgmt.) |
90812 | Office/OP Interactive Psychotherapy, 45‐50 min. |
90813 | Office/OP Interactive Psychotherapy, 45‐50 min. (w/eval. and mgmt.) |
90814 | Office/OP Interactive Psychotherapy, 75‐80 min. |
90815 | Office/OP Interactive Psychotherapy, 75‐80 min. (w/eval. and mgmt.) |
90816 | IP, Partial Hosp. or Res. Insight, Beh. Mod., or Supportive Psychotherapy, 20‐30 min. |
90817 | IP, Partial Hosp. or Res. Insight, Beh. Mod., or Supportive Psychotherapy, 20‐30 min. (w/eval. and mgmt.) |
90818 | IP, Partial Hosp. or Res. Insight, Beh. Mod., or Supportive Psychotherapy, 45‐50 min. |
90819 | IP, Partial Hosp. or Res. Insight, Beh. Mod., or Supportive Psychotherapy, 45‐50 min. (w/eval. and mgmt.) |
90821 | IP, Partial Hosp. or Res. Insight, Beh. Mod., or Supportive Psychotherapy, 75‐80 min. |
90822 | IP, Partial Hosp. or Res. Insight, Beh. Mod., or Supportive Psychotherapy, 45‐50 min. (w/eval. and mgmt.) |
90823 | IP, Partial Hosp. or Res. Interactive Psychotherapy, 20‐30 min. |
90824 | IP, Partial Hosp. or Res. Interactive Psychotherapy, 20‐30 min. (w/eval. and mgmt.) |
90826 | IP, Partial Hosp. or Res. Interactive Psychotherapy, 45‐50 min. |
90827 | IP, Partial Hosp. or Res. Interactive Psychotherapy, 45‐50 min. (w/eval. and mgmt.) |
90828 | IP, Partial Hosp. or Res. Interactive Psychotherapy, 75‐80 min. |
90829 | IP, Partial Hosp. or Res. Interactive Psychotherapy, 75‐80 min. (w/eval. and mgmt.) |
90845 | Other Psychotherapy, Psychoanalysis |
90846 | Other Psychotherapy, Family Psychotherapy (wo/patient present) |
90847 | Other Psychotherapy, Family Psychotherapy (w/patient present) |
90849 | Other Psychotherapy, Multiple‐family Group Psychotherapy |
90853 | Other Psychotherapy, Group Psychotherapy (other than multiple family‐group) |
90857 | Other Psychotherapy, Interactive Group Psychotherapy |
90875 | Individual Psychophysiological Psychotherapy, 20‐30 min. |
90876 | Individual Psychophysiological Psychotherapy, 45‐50 min. |
90880 | Hypnotherapy |
90882 | Environ. Intervention for Medical Mgmt. Purposes |
90841 | Individual Medical Psychotherapy by Physician w/Continuing Diagnostic Eval. and Drug Mgmt., time unspecified (code no longer used) |
90842 | Individual Medical Psychotherapy by Physician w/Continuing Diagnostic Eval. and Drug Mgmt., 75‐80 min |
90843 | Individual Medical Psychotherapy by Physician w/Continuing Diagnostic Eval. and Drug Mgmt., 20‐30 min |
90844 | Individual Medical Psychotherapy by Physician w/Continuing Diagnostic Eval. and Drug Mgmt., 45‐50 min |
90855 | Interactive Individual Medical Psychotherapy |
* includes discontinued codes that may still appear in the claims data. |
Project conducted by:
Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and
Outcomes, and Center for Education and Research on Mental Health Therapeutics
Institute for Health, Health Care Policy, and Aging Research
Rutgers University