Abstract
Objective:
This study aimed to use claims data to calculate incremental 2022 health care expenditure estimates for children with tic disorders relative to children without tic disorders.
Methods:
Children ages 6–17 years with tic disorders were identified in the Merative MarketScan Multi-State Medicaid (N=6,277) and MarketScan Commercial (employer-sponsored insurance [ESI]; N=6,955) databases via inpatient and outpatient claims and were compared with children without tic disorders, matched at a 1:8 ratio on age, sex, and coverage type. Presence of 12 types of co-occurring disorders was identified. Analyses were stratified by insurance type. Individual-level total expenditures and total inpatient, total outpatient, outpatient psychological services, and filled prescription medication expenditures were calculated and compared by tic disorder status. Two-part regression models for Medicaid and generalized linear regression models for ESI were fit to estimate the difference in expenditures for children with versus without tic disorders, with sex, age, and presence of individual co-occurring disorders as covariates.
Results:
In 2022, mean per-person expenditures for children with tic disorders were $4,549 in the Medicaid sample and $9,870 in the ESI sample—more than twice as high as totals for children without tic disorders. The adjusted mean difference in expenditures between children with and children without tic disorders was −$15 (nonsignificant) in the Medicaid sample and $1,641 in the ESI sample (p<0.001).
Conclusions:
This study documents substantial health care utilization and expenditures for children with tic disorders, although higher mean expenditures relative to children without tic disorders largely reflect differences in the prevalence of co-occurring disorders.
Approximately 1 in 50 children have Tourette’s syndrome (TS) or a persistent tic disorder (1, 2). Tic disorders are characterized by the presence of motor tics, vocal tics, or both—tics are “sudden, rapid, recurrent, nonrhythmic motor movement(s) or vocalization(s)” (3). Criteria for a diagnosis of TS or a persistent tic disorder require the presence of tics for at least 1 year (both motor and vocal tics for TS and either motor or vocal tics for persistent tic disorder); provisional tic disorder includes the presence of tics for less than 1 year (3). Co-occurring disorders, including attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and anxiety, are common among children with tic disorders (4, 5). Treatment of tic disorders, when indicated because of severity or functional impairment, includes medication and behavioral therapy and is often complicated by co-occurring disorders, which may require different medications or therapy (6–8).
Tic disorders are associated with increased health care needs (4, 5, 9, 10). During 2000–2007, children diagnosed as having a tic disorder who had employer-sponsored insurance (ESI) were more likely than those without a tic disorder to access mental health services—including psychotherapy, inpatient mental health care, and emergency mental health care—and to fill a prescription for psychotropic medication (5). According to parent-reported data from the 2007 National Survey of Children’s Health, children with TS had similar or greater health care needs—including higher prevalence of co-occurring disorders requiring treatment, need for special therapy, receipt of mental health treatment, and receipt of medication for difficulties with emotions, concentration, behavior, or ADHD—compared with children with asthma, a common childhood condition (4).
Although estimates of incremental health care costs have been published for other neurodevelopmental disorders (11–17), less is known about costs associated with tic disorders. A German study estimated gross medical and productivity costs for adults with TS; medical costs were primarily related to hospitalizations and medications (18). Documentation of incremental cost estimates for tic disorders and cost differences based on the presence of co-occurring disorders can be used to assess the impact of these disorders. The objective of this study was to use claims data to calculate incremental 2022 health care expenditure estimates for children with tic disorders relative to children without tic disorders, both unadjusted and adjusted for co-occurring disorders.
METHODS
Data Source and Inclusion Criteria
This study used data from 2021 and 2022 enrollment files and service and pharmacy claims from the Merative MarketScan Multi-State Medicaid and the MarketScan Commercial (ESI) databases. These research databases reflect the health care service use of individuals covered by, respectively, participation in Medicaid or the Children’s Health Insurance Program (CHIP) in approximately eight to 10 deidentified states or enrollment in a nationwide sample of ESI plans. MarketScan data are deidentified; therefore, the Centers for Disease Control and Prevention deemed the study as not involving human subjects and not needing institutional review board approval.
Children were included in the analysis if they met the following criteria: ages 6–17 years; at least 330 days of enrollment in Medicaid-CHIP or ESI in 2022; at least 11 months of prescription drug and mental health or substance use data in the MarketScan research data sets for 2022; and at least one inpatient, outpatient, or prescription medication claim in 2022.
Study Case Definitions
Children were considered to have a tic disorder if they had at least two outpatient claims (≥7 days apart) or at least one inpatient claim with an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code of F95.X (tic disorders) or G25.69 (tics of organic origin) from January 1, 2021, to December 31, 2022. Data from 2021 were incorporated into the tic disorder identification criteria to increase the opportunity to identify children with these disorders, because multiyear case ascertainment windows may improve sensitivity in identifying neurodevelopmental disorders in claims data (19). We examined all tic disorders together because the ICD-10-CM diagnosis codes present in health care administrative data have been shown to accurately reflect clinical diagnoses of tic disorders overall (20). Children with no claims with a tic disorder diagnosis code throughout 2021 and 2022 were eligible for inclusion in the comparison group of children without tic disorders; these children could have other disorders. Other children with claims with tic disorder diagnosis codes were excluded from the study because they had only one outpatient claim or two or more outpatient claims fewer than 7 days apart.
We included 12 co-occurring disorders in the analysis, given their high prevalence of co-occurrence with tic disorders: ADHD, anxiety disorders, conduct disorder or oppositional defiant disorder, depressive disorders, autism spectrum disorder, speech and language disorders, learning disorders, OCD, intellectual disability, bipolar disorder, eating disorders (anorexia, bulimia nervosa, binge eating disorder, and avoidant or restrictive food intake disorder), and body-focused repetitive behavior disorders (trichotillomania and excoriation disorder) (5, 21–24). A case definition similar to that used for tic disorders (at least two outpatient claims ≥7 days apart or at least one inpatient claim with a diagnosis code) was used to identify co-occurring disorders (see Table S1 in the online supplement to this article for ICD-10-CM codes).
For count-related statistics, unique inpatient encounters were deduplicated by admission and discharge dates. Outpatient claims with the same service date and provider type were combined to define unique outpatient encounters. Outpatient encounters for psychological services were identified by CPT and Healthcare Common Procedure Coding System codes (Table S2 in the online supplement) and were deduplicated by service date and provider type. Claims for filled prescription medications were deduplicated by service date and National Drug Code.
Statistical Analyses
Limited demographic information was available: sex, age, and, for the Medicaid-CHIP sample only, race and ethnicity (White, Black, Hispanic, other, or missing). Children were categorized by whether they had capitated health care plans only, noncapitated plans (e.g., fee-for-service) only, or both. In the Medicaid-CHIP sample, information was also available on qualification for Medicaid or CHIP by being in the foster care system, having a disability, or having low household income or meeting other eligibility criteria.
Because of differences in the distributions of demographic characteristics of children with versus children without tic disorders (24, 25), children with tic disorders were matched at a 1:8 ratio to a comparison group of children without tic disorders in 2022 by using propensity score methods. Propensity scores were calculated by using a logistic regression to model the likelihood of having a tic disorder by sex, birth year, and coverage type (capitated, noncapitated, or both) via a greedy algorithm approach (26).
To calculate total per-person expenditures, payments for all inpatient claims, outpatient claims (including claims for psychological services), and prescription medication fills were summed. Some claims had negative expenditures associated with them (as adjustments to data errors); one child with negative expenditures was excluded from the analytic sample.
All analyses were stratified by insurance type (Medicaid-CHIP or ESI). Percentages of children stratified by demographic subgroup and presence of select co-occurring disorders were calculated for the tic disorder and no tic disorder groups. Numbers of encounters and total expenditures, overall and by encounter type, were summarized with means, standard deviations, medians, and 10th–90th percentiles. Fisher’s exact tests or two-sample t tests were used to determine whether statistically significant differences existed between the tic disorder and no tic disorder groups (α<0.05).
With total expenditure as the outcome, two-part regression models (for the Medicaid-CHIP sample with an excess number of zeros) and generalized linear models (for the ESI sample) were fit to estimate the incremental or adjusted differences in expenditures between the tic disorder and no tic disorder groups (see online supplement). Mean expenditures among children with select co-occurring disorders and tic disorders were compared with those among children without tic disorders but with the same co-occurring disorders by t tests and were considered significantly different if the confidence interval did not include zero. Analyses were conducted in SAS, version 9.4, and R, version 4.2.2, and statistical significance was assessed (α<0.05).
RESULTS
Sample Characteristics
The demographic characteristics and prevalence of co-occurring disorders among children with and those without tic disorders, before matching, are shown in Table S3 in the online supplement. After we matched children with tic disorders to children without tic disorders by age, sex, and coverage type within each insurance plan type, the final analytic samples consisted of 56,493 children with Medicaid-CHIP and 62,595 children with ESI (Table 1). In the Medicaid-CHIP sample, a higher percentage of children with tic disorders (71.8%) than of children without tic disorders (51.7%) were White. Most children in the Medicaid-CHIP sample were eligible based on low household income or meeting other eligibility criteria, regardless of tic disorder status.
TABLE 1.
Distribution of demographic characteristics and select co-occurring disorders in an analytic sample of sex- and age-matched U.S. children with or without a tic disorder, by insurance type, 2022a
| Demographic characteristic | Medicaid-CHIP sample |
ESI sample |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| With a tic disorder (N=6,277) |
Without a tic disorder (N=50,216)b |
p | With a tic disorder (N=6,955) |
Without a tic disorder (N=55,640)b |
p | |||||
| N | % | N | % | N | % | N | % | |||
|
| ||||||||||
| Age group, years | ||||||||||
| 6–11 | 2,757 | 43.9 | 22,056 | 43.9 | 1.000 | 2,906 | 41.8 | 23,248 | 41.8 | 1.000 |
| 12–17 | 3,520 | 56.1 | 28,160 | 56.1 | 1.000 | 4,049 | 58.2 | 32,392 | 58.2 | 1.000 |
| Sex | ||||||||||
| Male | 4,149 | 66.1 | 33,192 | 66.1 | 1.000 | 4,414 | 63.5 | 35,312 | 63.5 | 1.000 |
| Female | 2,128 | 33.9 | 17,024 | 33.9 | 1.000 | 2,541 | 36.5 | 20,328 | 36.5 | 1.000 |
| Race-ethnicityc | ||||||||||
| Non-Hispanic White | 4,506 | 71.8 | 25,957 | 51.7 | <0.001 | na | na | na | ||
| Non-Hispanic Black | 833 | 13.3 | 15,896 | 31.7 | <0.001 | na | na | na | ||
| Hispanic | 129 | 2.1 | 1,433 | 2.9 | <0.001 | na | na | na | ||
| Other | 246 | 3.9 | 2,713 | 5.4 | <0.001 | na | na | na | ||
| Missing | 563 | 9.0 | 4,217 | 8.4 | 0.130 | na | na | na | ||
| Type of insurance plan coverage | ||||||||||
| Both capitated and noncapitated | 395 | 6.3 | 3,160 | 6.3 | 1.000 | 12 | 0.2 | 96 | 0.2 | 1.000 |
| Capitated only | 5,236 | 83.4 | 41,888 | 83.4 | 1.000 | 962 | 13.8 | 7,696 | 13.8 | 1.000 |
| Noncapitated only | 646 | 10.3 | 5,168 | 10.3 | 1.000 | 5,840 | 84.0 | 46,720 | 84.0 | 1.000 |
| Missing | 0 | 0.0 | 0 | 0.0 | na | 141 | 2.0 | 1,128 | 2.0 | 1.000 |
| Basis of eligibilityd | ||||||||||
| Disability | 309 | 4.9 | 1,791 | 3.6 | <0.001 | na | na | na | ||
| Foster care | 224 | 3.6 | 1,041 | 2.1 | <0.001 | na | na | na | ||
| Low household income or other | 5,744 | 91.5 | 47,384 | 94.4 | <0.001 | na | na | na | ||
| Co-occurring disorder | ||||||||||
| None | 1,285 | 20.5 | 35,810 | 71.3 | <0.001 | 2,054 | 29.5 | 45,521 | 81.8 | <0.001 |
| Any specified | 4,992 | 79.5 | 14,406 | 28.7 | <0.001 | 4,901 | 70.5 | 10,119 | 18.2 | <0.001 |
| 1–2 | 3,044 | 48.5 | 11,680 | 23.3 | <0.001 | 3,376 | 48.5 | 8,588 | 15.4 | <0.001 |
| ≥3 | 1,948 | 31.0 | 2,726 | 5.4 | <0.001 | 1,525 | 21.9 | 1,531 | 2.8 | <0.001 |
| ADHD | 3,569 | 56.9 | 7,585 | 15.1 | <0.001 | 3,130 | 45.0 | 5,314 | 9.6 | <0.001 |
| Anxiety disorders | 2,647 | 42.2 | 4,257 | 8.5 | <0.001 | 3,116 | 44.8 | 4,758 | 8.6 | <0.001 |
| Conduct disorder or oppositional defiant disorder | 1,068 | 17.0 | 2,455 | 4.9 | <0.001 | 461 | 6.6 | 695 | 1.2 | <0.001 |
| Depressive disorders | 1,562 | 24.9 | 3,932 | 7.8 | <0.001 | 1,316 | 18.9 | 2,576 | 4.6 | <0.001 |
| ASD | 997 | 15.9 | 1,780 | 3.5 | <0.001 | 747 | 10.7 | 1,157 | 2.1 | <0.001 |
| Speech and language disorder | 832 | 13.3 | 3,159 | 6.3 | <0.001 | 355 | 5.1 | 784 | 1.4 | <0.001 |
| Learning disorders | 179 | 2.9 | 617 | 1.2 | <0.001 | 96 | 1.4 | 161 | 0.3 | <0.001 |
| OCD | 323 | 5.1 | 117 | 0.2 | <0.001 | 714 | 10.3 | 302 | 0.5 | <0.001 |
| Intellectual disability | 241 | 3.8 | 638 | 1.3 | <0.001 | 37 | 0.5 | 75 | 0.1 | <0.001 |
| Bipolar disorder | 231 | 3.7 | 395 | 0.8 | <0.001 | 122 | 1.8 | 142 | 0.3 | <0.001 |
| Eating disorderse | 106 | 1.7 | 148 | 0.3 | <0.001 | 149 | 2.1 | 247 | 0.4 | <0.001 |
| BFRBDsf | 57 | 0.9 | 49 | 0.1 | <0.001 | 74 | 1.1 | 54 | 0.1 | <0.001 |
Data are from the Merative MarketScan Multi-State Medicaid and the MarketScan Commercial databases. The prevalence of having a tic disorder and a co-occurring disorder was based on identification of diagnosis codes in 2021 or 2022, including at least two outpatient claims ≥7 days apart or at least one inpatient claim with a tic disorder and a corresponding co-occurring disorder diagnosis code. ASD, autism spectrum disorder; BFRBDs, body-focused repetitive behavior disorders; CHIP, Children’s Health Insurance Program; ESI, employer-sponsored insurance; na, not available or not applicable; OCD, obsessive-compulsive disorder.
Children without tic disorders were matched 8:1 to those with tic disorders by age, sex, and type of insurance plan coverage.
Race and ethnicity data were only available for the Medicaid-CHIP sample.
Basis of eligibility was only applicable for Medicaid-CHIP data; because children may qualify for multiple categories, we first identified children who ever qualified on the basis of having a disability, then those ever in foster care, and then those who qualified on the basis of low household income or meeting other eligibility criteria, creating three mutually exclusive categories.
Eating disorders consisted of anorexia, bulimia nervosa, binge eating disorder, and avoidant or restrictive food intake disorder.
BFRBDs consisted of trichotillomania and excoriation disorder.
Co-occurring disorders were more common among children with than children without tic disorders (Table 1). For the Medicaid-CHIP sample, 79.5% of children with a tic disorder had at least one co-occurring disorder, compared with 28.7% of children without a tic disorder; the corresponding numbers for the ESI sample were 70.5% and 18.2%, respectively. ADHD was the most common co-occurring disorder regardless of tic disorder status or insurance type, followed by anxiety disorders and depressive disorders. Conduct disorder or oppositional defiant disorder, speech and language disorders, and learning disorders were more common among children with tic disorders in the Medicaid-CHIP sample than among children with tic disorders in the ESI sample. OCD co-occurred with tic disorders more commonly in the ESI sample than in the Medicaid-CHIP sample. Children with Medicaid-CHIP had a higher percentage of co-occurring disorders than children with ESI, regardless of tic disorder status.
Distribution of Encounter Types
Regardless of insurance type, a higher percentage of children with tic disorders had inpatient and outpatient encounters, outpatient psychological services, and filled prescriptions in 2022 than children without tic disorders (Table 2). Similarly, across all encounter types, the mean number of per-person encounters for children with a tic disorder was at least twice as high as the mean for those without a tic disorder. Children with tic disorders and Medicaid-CHIP had an average of 30 outpatient encounters and 22 filled prescriptions in 2022, which translates to 2.5 outpatient encounters and approximately two filled prescriptions per month; the corresponding means for children with tic disorders and ESI were close to two outpatient encounters and one filled prescription per month.
TABLE 2.
Health care encounters among children with and children without tic disorders, by insurance type, 2022a
| Medicaid-CHIP sampleb |
ESI samplec |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Encounter type, tic disorder status | N | % | M±SD | Median | 10th–90th percentile | N | % | M±SD | Median | 10th–90th percentile |
|
| ||||||||||
| Inpatient | ||||||||||
| With | 384 | 6.1 | 0.10±0.56 | 0.0 | 0–0 | 318 | 4.6 | 0.08±0.53 | 0.0 | 0–0 |
| Without | 1,045 | 2.1 | 0.03±0.29 | 0.0 | 0–0 | 666 | 1.2 | 0.02±0.19 | 0.0 | 0–0 |
| Outpatient (all) | ||||||||||
| With | 6,269 | 99.9 | 29.8±40.5 | 17.0 | 5.0–68.0 | 6,940 | 99.8 | 21.5±27.0 | 13.0 | 3.0–48.0 |
| Without | 49,507 | 98.6 | 13.6±27.7 | 6.0 | 1.0–31.0 | 54,105 | 97.2 | 9.0±16.1 | 5.0 | 1.0–20.0 |
| Outpatient psychological services | ||||||||||
| With | 2,917 | 46.5 | 10.3±25.4 | 0.0 | 0–30.0 | 2,807 | 40.4 | 6.8±17.3 | 0.0 | 0–21.0 |
| Without | 7,966 | 15.9 | 3.3±14.9 | 0.0 | 0–6.0 | 5,874 | 10.6 | 1.6±9.4 | 0.0 | 0–1.0 |
| Filled prescriptions | ||||||||||
| With | 5,722 | 91.2 | 22.2±24.9 | 15.0 | 1.0–53.0 | 6,098 | 87.7 | 13.6±15.5 | 9.0 | 0–33.0 |
| Without | 33,374 | 66.5 | 6.6±13.2 | 2.0 | 0–18.0 | 38,294 | 68.8 | 4.2±7.8 | 2.0 | 0–11.0 |
Data are from the Merative MarketScan Multi-State Medicaid and the MarketScan Commercial databases. Children without tic disorders were matched 8:1 to those with tic disorders by age, sex, and type of insurance plan coverage. CHIP, Children’s Health Insurance Program; ESI, employer-sponsored insurance.
N=6,277 with a tic disorder; N=50,216 without a tic disorder. For all encounter types, p<0.001 for means and percentages.
N=6,955 with a tic disorder; N=55,640 without a tic disorder. For all encounter types, p<0.001 for means and percentages.
Expenditures
Mean and median expenditures were at least twice as high for children with tic disorders as for children without tic disorders for both the Medicaid-CHIP and ESI samples in 2022 (Table 3). Children with Medicaid-CHIP and a tic disorder had mean and median total expenditures of $4,549 and $425, respectively, compared with $1,836 and $4, respectively, among children without a tic disorder. Children with ESI and a tic disorder had mean and median total expenditures of $9,870 and $3,144, respectively, compared with $3,539 and $842, respectively, among children without a tic disorder. Expenditures were higher for children with tic disorders and ESI than for children with tic disorders and Medicaid-CHIP across all expenditure categories except outpatient psychological services.
TABLE 3.
Service expenditures by insurance type and encounter type among children with and children without a tic disorder, 2022a
| Encounter type, tic disorder status | Medicaid-CHIP sample ($)b |
ESI sample ($)c |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| M±SD | Median | 10th–90th percentile | Mean differenced | 95% CI | M±SD | Median | 10th–90th percentile | Mean differenced | 95% CI | |
|
| ||||||||||
| Total, all encounter types | 2,712 | 2,217–3,208 | 6,331 | 5,543–7,120 | ||||||
| With | 4,549±19,203 | 425 | 0–8,732 | 9,870±32,965 | 3,144 | 670–18,263 | ||||
| Without | 1,836±15,953 | 4 | 0–2,325 | 3,539±17,357 | 842 | 158–5,707 | ||||
| Inpatient | 335 | 55–616 | 1,557 | 1,049–2,064 | ||||||
| With | 656±10,803 | 0 | 0–0 | 2,111±21,264 | 0 | 0–0 | ||||
| Without | 321±9,745 | 0 | 0–0 | 554±10,551 | 0 | 0–0 | ||||
| Outpatient (all) | 1,602 | 1,353–1,850 | 3,594 | 3,200–3,987 | ||||||
| With | 2,689±9,796 | 148 | 0–5,641 | 5,890±16,450 | 2,279 | 499–12,312 | ||||
| Without | 1,088±6,283 | 0 | 0–1,716 | 2,296±8,848 | 714 | 134–4,462 | ||||
| Outpatient psychological services | 1,009 | 816–1,202 | 903 | 783–1,023 | ||||||
| With | 1,357±7,692 | 0 | 0–1,315 | 1,195±4,935 | 0 | 0–2,686 | ||||
| Without | 348±3,709 | 0 | 0–0 | 292±3,580 | 0 | 0–85 | ||||
| Filled prescriptions | 774 | 508–1,040 | 1,173 | 942–1,404 | ||||||
| With | 1,204±10,240 | 55 | 0–2,379 | 1,873±9,472 | 266 | 0–3,295 | ||||
| Without | 429±9,293 | 0 | 0–251 | 700±7,379 | 28 | 0–702 | ||||
Data are from the Merative MarketScan Multi-State Medicaid and the MarketScan Commercial databases. Children without tic disorders were matched 8:1 to those with tic disorders by age, sex, and type of insurance plan coverage. CHIP, Children’s Health Insurance Program; ESI, employer-sponsored insurance.
N=6,277 with a tic disorder; N=50,216 without a tic disorder.
N=6,955 with a tic disorder; N=55,640 without a tic disorder.
Mean differences between children with and children without tic disorders may not be exactly equal to the differences in expenditures presented due to rounding.
Mean and median expenditures were generally higher for children with tic disorders than for children of the same age and sex without tic disorders (Table S4 in the online supplement) and who had the same co-occurring disorder (Table 4). For example, children with a tic disorder and ADHD had mean and median Medicaid-CHIP expenditures of $5,711 and $795, respectively, and children with ADHD but without a tic disorder had mean and median Medicaid-CHIP expenditures of $4,548 and $348, resulting in mean and median differences of $1,163 and $447 (median differences are shown in Table S5 in the online supplement). The mean difference in total expenditures between children with (vs. without) a tic disorder and a specific co-occurring disorder was significantly higher for children with Medicaid-CHIP and ADHD, conduct disorder or oppositional defiant disorder, and depressive disorders. For children with ESI, the mean difference in total expenditures was significantly higher for children with a tic disorder and ADHD, anxiety, conduct disorder or oppositional defiant disorder, depressive disorders, learning disorders, and eating disorders, compared with children without a tic disorder and the same co-occurring disorder. Absolute differences in mean and median expenditures were consistently higher for children with ESI than for children with Medicaid-CHIP (learning disorders and OCD had negative differences in the latter sample); relative differences were less consistent (Table S5 in the online supplement).
TABLE 4.
Total expenditures by insurance type and select co-occurring disorders among children with and children without a tic disorder, 2022a
| Medicaid-CHIP sample ($)b |
ESI sample ($)c |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Co-occurring disorder, tic disorder status | M±SD | Median | 10th–90th percentile | Mean differenced | 95% CI | M±SD | Median | 10th–90th percentile | Mean differenced | 95% CI |
|
| ||||||||||
| ADHD | 1,163 | 287 to 2,038 | 5,233 | 3,863 to 6,603 | ||||||
| With | 5,711±20,514 | 795 | 0–11,566 | 12,296±36,985 | 4,613 | 1,221–23,597 | ||||
| Without | 4,548±24,854 | 348 | 0–8,125 | 7,063±16,516 | 2,962 | 778–13,196 | ||||
| Anxiety disorders | 492 | −632 to 1,615 | 5,108 | 3,481 to 6,734 | ||||||
| With | 6,134±20,280 | 685 | 0–12,956 | 14,590±41,739 | 5,106 | 1,208–29,369 | ||||
| Without | 5,642±27,138 | 394 | 0–10,785 | 9,482±24,802 | 3,357 | 766–19,116 | ||||
| Conduct or oppositional defiant disorder | 3,351 | 1,165 to 5,538 | 8,518 | 2,813 to 14,223 | ||||||
| With | 10,287±30,427 | 1,265 | 0–22,415 | 20,688±58,754 | 7,159 | 1,618–47,356 | ||||
| Without | 6,936±30,393 | 586 | 0–15,793 | 12,170±25,676 | 4,153 | 918–29,384 | ||||
| Depressive disorders | 3,342 | 1,710 to 4,974 | 11,303 | 7,779 to 14,828 | ||||||
| With | 8,831±28,660 | 907 | 0–21,786 | 22,870±62,721 | 7,868 | 1,663–50,642 | ||||
| Without | 5,489±25,615 | 238 | 0–11,567 | 11,567±24,830 | 4,280 | 840–26,865 | ||||
| ASD | 236 | −2,171 to 2,644 | 3,255 | −1,251 to 7,760 | ||||||
| With | 10,411±28,105 | 1,997 | 0–25,486 | 21,534±54,200 | 7,906 | 1,382–48,777 | ||||
| Without | 10,175±35,674 | 1,910 | 0–21,787 | 18,280±39,400 | 5,565 | 760–48,896 | ||||
| Speech and language disorders | 1,201 | −1,112 to 3,514 | 2,588 | −3,131 to 8,306 | ||||||
| With | 7,438±28,853 | 1,185 | 0–14,494 | 19,993±43,800 | 7,381 | 1,654–45,003 | ||||
| Without | 6,237±35,072 | 940 | 0–9,366 | 17,406±49,150 | 4,575 | 632–39,616 | ||||
| Learning disorders | −4,406 | −10,272 to 1,461 | 7,079 | 634 to 13,525 | ||||||
| With | 6,847±29,202 | 1,080 | 0–11,966 | 15,448±28,890 | 6,650 | 2,525–38,526 | ||||
| Without | 11,252±50,617 | 1,260 | 44–14,480 | 8,369±17,635 | 3,411 | 1,006–15,018 | ||||
| OCD | −2,644 | −7,366 to 2,078 | 2,851 | −3,536 to 9,238 | ||||||
| With | 6,306±16,715 | 1,235 | 0–15,603 | 20,542±61,777 | 6,071 | 1,321–43,447 | ||||
| Without | 8,949±23,824 | 1,959 | 0–22,482 | 17,691±39,792 | 5,476 | 1,044–43,909 | ||||
| Intellectual disability | 2,717 | −6,158 to 11,591 | 28,505 | −9,295 to 66,305 | ||||||
| With | 22,211±59,614 | 4,118 | 182–49,821 | 54,553±111,539 | 19,758 | 2,047–113,991 | ||||
| Without | 19,495±60,001 | 3,089 | 162–45,090 | 26,048±31,064 | 13,529 | 2,348–65,573 | ||||
| Bipolar disorder | 1,343 | −6,576 to 9,262 | 13,762 | −5,420 to 32,944 | ||||||
| With | 15,307±40,192 | 1,962 | 0–34,675 | 40,270±101,122 | 14,259 | 2,955–95,383 | ||||
| Without | 13,964±60,509 | 604 | 0–31,137 | 26,508±38,495 | 11,164 | 1,559–67,211 | ||||
| Eating disorderse | 2,349 | −5,848 to 10,547 | 15,403 | 880 to 29,925 | ||||||
| With | 11,765±26,410 | 1,821 | 0–38,362 | 40,804±79,742 | 14,637 | 2,647–111,044 | ||||
| Without | 9,416±39,874 | 505 | 0–19,099 | 25,401±53,632 | 7,905 | 1,458–58,317 | ||||
| BFRBDsf | 5,083 | −2,182 to 12,348 | 7,127 | −2,777 to 17,031 | ||||||
| With | 9,484±26,061 | 1,725 | 0–19,669 | 17,502±38,053 | 5,410 | 1,265–34,306 | ||||
| Without | 4,401±8,108 | 981 | 0–10,588 | 10,375±17,069 | 3,549 | 1,088–36,022 | ||||
Data are from the Merative MarketScan Multi-State Medicaid and the MarketScan Commercial databases. Children without tic disorders were matched 8:1 to those with tic disorders by age, sex, and type of insurance plan coverage. The numbers of children with each co-occurring disorder in each sample are reported in Table 1. ASD, autism spectrum disorder; BFRBDs, body-focused repetitive behavior disorders; CHIP, Children’s Health Insurance Program; ESI, employer-sponsored insurance; OCD, obsessive-compulsive disorder.
N=6,277 with a tic disorder; N=50,216 without a tic disorder.
N=6,955 with a tic disorder; N=55,640 without a tic disorder.
Mean differences between children with and children without tic disorders may not be exactly equal to the differences in expenditures presented due to rounding.
Eating disorders consisted of anorexia, bulimia nervosa, binge eating disorder, and avoidant or restrictive food intake disorder.
BFRBDs consisted of trichotillomania and excoriation disorder.
After adjustment for sex, age, and co-occurring disorders, a significant difference in mean expenditures was found between children with versus children without tic disorders in the ESI sample, with a mean difference in incremental expenditures of $1,641 (95% CI=$931–$2,351, p<0.001; results not shown). In contrast, adjusted expenditures for children with and for children without tic disorders in the Medicaid-CHIP sample were roughly equivalent, with an incremental mean difference of −$15.
DISCUSSION
The findings reported here document more frequent health care encounters and higher health care expenditures among children with versus children without tic disorders for each encounter type—inpatient, outpatient, outpatient psychological services, and filled prescriptions.
Co-occurring disorders are common among children with tic disorders, and impairment among individuals with tic disorders is often attributed to co-occurring disorders (5, 24, 27–33). We found that regardless of insurance type, children with tic disorders were two to four times more likely than children without tic disorders to have at least one co-occurring disorder. Among children with ESI for all co-occurring disorders and among children with Medicaid-CHIP for all disorders with the exception of learning disorders and OCD, mean and median expenditures were higher for children with (vs. without) tic disorders and each co-occurring disorder, although these findings were not always statistically significant. After adjustment for the presence of co-occurring disorders, children with tic disorders and Medicaid-CHIP had no greater expenditures compared with children without tic disorders; the difference in expenditures between children with versus children without tic disorders remained significant for children with ESI but was much smaller than the unadjusted differences for co-occurring disorders. Thus, although tic disorders are associated with increased expenditures among children with co-occurring disorders, co-occurring disorders account for most of the differences in pediatric health care expenditures associated with tic disorders.
The findings that the prevalence of OCD among children with tic disorders was lower than estimates of co-occurring OCD previously reported in clinical and community-based studies (27–29, 34) and was lower in the comparison group relative to estimates from the general population (3, 35) suggest that claims data may underestimate the prevalence of OCD. These findings may be explained by underdiagnosis of OCD, as previously reported for other psychiatric diagnoses (36, 37). Previous studies have documented that children with TS and co-occurring disorders have increased health care needs and use (e.g., medication, specialty care, and psychiatric hospitalization) and are less likely to receive effective care coordination compared with children with only a tic disorder (4, 38). Despite the high prevalence of co-occurring disorders in this population of children with tic disorders, only about half of children with Medicaid-CHIP and approximately two in five children with ESI had psychological services encounters; similar percentages of children with tic disorders were reported in previous studies to have received psychotherapy (10%–35%) (5, 8). This finding suggests underutilization of behavioral treatment by children with tic disorders. Practice guidelines for TS and persistent tic disorders recommend assessment for co-occurring disorders, inclusion of care for co-occurring disorders as part of the treatment plan, and comprehensive behavioral intervention for tics (CBIT) as a first-line behavioral treatment (7). Increasing access to mental health care through approaches such as integrated care models and mental health parity could potentially help reduce costs and improve outcomes for children with tic disorders and co-occurring conditions (39–41).
Consistent with previous studies, the population of children with diagnosed tic disorders was mostly male and non-Hispanic White (24, 25). Although approximately half of children without tic disorders in the Medicaid-CHIP sample were non-Hispanic White, nearly three-quarters of children with tic disorders in this sample were non-Hispanic White. This difference may represent less identification of tic disorders among people belonging to other racial-ethnic groups (42).
Health care expenditures are only one aspect of economic costs associated with tic disorders. In a German study of gross costs associated with TS among adults, estimates of indirect costs, including unemployment and absenteeism, were greater than estimates of direct medical costs; however, the study did not include a comparison group of adults without TS (18). Other studies have reported additional costs associated with tic disorders among children. In a survey conducted in 2014, 35% of parents of children with TS but without ADHD and 56% of parents of children with both TS and ADHD reported family financial or occupational problems as a result of their child’s TS or ADHD (43). Children with TS are also more likely to have an individualized education program (IEP) compared with children without TS, even after adjustment for co-occurring disorders (30); IEPs are associated with additional costs for schools (44). Furthermore, in a study of adults with TS, 29% were unemployed, compared with 7.5% of adults matched by age group and location on the basis of census data (45). Future studies could explore the broad costs associated with tic disorders to better understand the economic impact of these disorders.
This study had several limitations. First, the MarketScan data sets are large convenience samples of individuals with Medicaid-CHIP or with ESI coverage, and study results may not be generalizable to all children with these types of insurance, children with other types of insurance, or children without insurance. Of note, the MarketScan Medicaid-CHIP sample includes only a selected number of geographically dispersed states and is not representative of the full U.S. population of individuals with Medicaid-CHIP coverage. Another limitation was that MarketScan data include only expenditures for services that were at least partially paid by insurance, which likely results in underestimations of total expenditures. Of note, 55.3% of psychiatrists during 2009–2010 accepted private fee-for-service insurance, and 43.1% accepted Medicaid (46). Services paid for completely by other means (including out-of-pocket payment), such as complementary and alternative medicine (47), are not represented in this study’s results. Owing to the absence of race and ethnicity information in ESI data, race and ethnicity were not included in the matching criteria. Future studies with a different data source could examine the relationships of these and other factors with health care encounters and expenditures. Finally, our case definition of tic disorders required at least two outpatient encounters (≥7 days apart) or at least one inpatient encounter occurring in 2021 or 2022; this definition may have inflated the between-group difference in the number of encounters because individuals in the tic disorder group were required, by definition, to have encounters.
CONCLUSIONS
Despite the limitations of this study, the findings demonstrate substantial health care use and expenditures among children with tic disorders with either Medicaid-CHIP or ESI. Co-occurring disorders are common among children with tic disorders and are associated with elevated health care expenditures. The low proportions of Black and Hispanic children with tic disorders in the Medicaid-CHIP sample suggest potential underdiagnosis in these populations. Improved access to care might lead to identification of more children with tic disorders and to those children receiving appropriate mental health care. Future studies could identify factors associated with differences in use of psychological services, including CBIT, and assess whether improved access to such services reduces health care expenditures.
Supplementary Material
HIGHLIGHTS.
In 2022, mean total health care expenditures, including inpatient, outpatient, and prescription medication expenses, for children with tic disorders were more than twice as high as those for children without tic disorders.
Co-occurring disorders were common among children with tic disorders, with attention-deficit hyperactivity disorder, anxiety disorders, and depressive disorders occurring most frequently.
After adjustment for co-occurring disorders, the mean difference in health care expenditures between children with versus without tic disorders decreased for both those with Medicaid and those with employer-sponsored insurance (ESI) but remained statistically significant only in the ESI sample.
Acknowledgments
The authors are grateful for Ms. Danielson’s leadership and mentorship throughout the development of this work. The authors also acknowledge Parul Gupta, Ph.D., for conducting preliminary analyses.
Footnotes
The findings and conclusions reported in this article are those of the authors and do not necessarily represent the official position of the CDC or the U.S. government.
The authors report no financial relationships with commercial interests.
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