REAL-WORLD ECONOMIC BURDEN AND HEALTHCARE UTILIZATION DRIVERS IN AUTISM SPECTRUM DISORDER: A LONGITUDINAL ANALYSIS OF EHR AND CLAIMS DATA (2017-2025)
Author(s)
Stacey Long1, Fato Kerma, MPH2;
1OMNY Health, Chief Strategy Officer, Atlanta, GA, USA, 2OMNY Health, New York, NY, USA
1OMNY Health, Chief Strategy Officer, Atlanta, GA, USA, 2OMNY Health, New York, NY, USA
OBJECTIVES: Evaluate longitudinal healthcare utilization and total charges for US-based patients with Autism Spectrum Disorder (ASD).
METHODS: A retrospective cohort study utilizing OMNY Health electronic health record (EHR) data from large US-based health systems (2017-2025) and linked open claims was performed. Patients with ICD-10 code of F84.0 were identified in the EHR and their linked claims were analyzed from time of first ASD diagnosis to last available claim. Healthcare utilization and associated charges were characterized overall and stratified by year and treatment setting/type.
RESULTS: 221,735 ASD patients were identified. Mean age was 15.6 years (SD 13.79); 25% were between 1-5 years in age; 22% between 6-10, 21% between 11-17, and 32% aged 18+ years. Most patients were male (73%) and had Private Health Insurance/BCBS (59.7%), followed by Medicaid (13.8%) and Medicare/Other Government (4.9%). 21.4% had Miscellaneous/Other insurance coverage. Mean total annualized charges were $5,545, with 81% of charges covering hospital outpatient/ambulatory services, 13% covering prescription drugs, and 6% covering inpatient/emergency department care. Annual charges trended upward year over year overall and for each setting, while the proportion of total charges was stable by care setting.
CONCLUSIONS: Outpatient and ambulatory care services represent the bulk of medical charges for patients diagnosed with ASD. The ASD diagnosis code F84.0 was rarely reported in the claims data. Commonly recommended ASD interventional services such as speech language therapy, applied behavioral analysis therapy, or programming for specialty tablet devices were rarely observed in the health system EHR data, as these services are typically delivered by specialty practices. ASD interventional services were found in the claims data, but often without an associated ASD diagnosis on the claim. Characterizing the ASD patient journey and cost of care in the US is a complex undertaking that requires consideration of the fragmented care delivery, coding practices, and reimbursement coverage for ASD services.
METHODS: A retrospective cohort study utilizing OMNY Health electronic health record (EHR) data from large US-based health systems (2017-2025) and linked open claims was performed. Patients with ICD-10 code of F84.0 were identified in the EHR and their linked claims were analyzed from time of first ASD diagnosis to last available claim. Healthcare utilization and associated charges were characterized overall and stratified by year and treatment setting/type.
RESULTS: 221,735 ASD patients were identified. Mean age was 15.6 years (SD 13.79); 25% were between 1-5 years in age; 22% between 6-10, 21% between 11-17, and 32% aged 18+ years. Most patients were male (73%) and had Private Health Insurance/BCBS (59.7%), followed by Medicaid (13.8%) and Medicare/Other Government (4.9%). 21.4% had Miscellaneous/Other insurance coverage. Mean total annualized charges were $5,545, with 81% of charges covering hospital outpatient/ambulatory services, 13% covering prescription drugs, and 6% covering inpatient/emergency department care. Annual charges trended upward year over year overall and for each setting, while the proportion of total charges was stable by care setting.
CONCLUSIONS: Outpatient and ambulatory care services represent the bulk of medical charges for patients diagnosed with ASD. The ASD diagnosis code F84.0 was rarely reported in the claims data. Commonly recommended ASD interventional services such as speech language therapy, applied behavioral analysis therapy, or programming for specialty tablet devices were rarely observed in the health system EHR data, as these services are typically delivered by specialty practices. ASD interventional services were found in the claims data, but often without an associated ASD diagnosis on the claim. Characterizing the ASD patient journey and cost of care in the US is a complex undertaking that requires consideration of the fragmented care delivery, coding practices, and reimbursement coverage for ASD services.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
EE34
Topic
Economic Evaluation
Topic Subcategory
Cost/Cost of Illness/Resource Use Studies
Disease
No Additional Disease & Conditions/Specialized Treatment Areas, SDC: Neurological Disorders, SDC: Pediatrics