Clinical Scorecard: Condition-Specific Incidence and Spending Among Children Using Medicaid
At a Glance
Category
Detail
Condition
Healthcare utilization and spending by clinical condition among children enrolled in Medicaid
Key Mechanisms
Retrospective claims analysis classified care as preventative, chronic-condition (CC), or nonchronic-condition (NCC) care and grouped claims by outpatient, inpatient, pharmacy, or emergency department setting.
Target Population
Children younger than 20 years enrolled in Medicaid across 12 states in 2022.
Care Setting
Medicaid claims across outpatient, inpatient, pharmacy, and emergency department settings.
Key Highlights
The analysis included 7.2 million children; 78.5% had at least one Medicaid claim.
Total expenditures were $22.3 billion, or $2,143 per member per year using an equal-distribution calculation.
Outpatient services accounted for 55.2% of total spending, inpatient services 25.2%, pharmacy 13.9%, and emergency department services 5.8%.
Preventative care was accessed by about 50% of utilizers and represented 8.5% of spending; CC care reached about 27% and represented 41.1% of spending.
Nearly 70% of utilizers received NCC care, which accounted for 50.4% of spending.
Guideline-Based Recommendations
Diagnosis
Conditions were categorized using the Pediatric Clinical Classification System and principal diagnosis; when a principal diagnosis was absent, the last diagnosis was carried forward for imputation.
Management
Not reported in the source.
Monitoring & Follow-up
Not reported in the source.
Risks
The validity of race data could not be evaluated because state-level collection and standardization may differ and the database lacked state identifiers.
Patient & Prescribing Data
Children younger than 20 years enrolled in Medicaid for any duration across 12 states; mean age was 10.4 years and mean enrollment was 295 days.
The study reports utilization and spending, not prescribing. Of enrolled children, 21.5% had no recorded Medicaid claims. Capitated plans predominated among utilizers (63.7%), while fee-for-service plans predominated among nonutilizers (63.9%).
Clinical Best Practices
The study classified a PECCS category as chronic when conditions on the AHRQ Chronic Condition Indicator list accounted for more than 75% of category spending.
The study classified a PECCS category as preventative when conditions on the American Academy of Family Physicians’ preventative-services list accounted for more than 75% of category spending; categories meeting neither threshold were classified as NCC.
