U.S. Department of Health and Human Services Office of Inspector General Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care OEI-07-17-00170 August 2019 Joanne M. Chiedi Acting Inspector General oig.hhs.gov Report in Brief U.S. Department of Health and Human Services August 2019 OEI-07-17-00170 Office of Inspector General Many Medicaid-Enrolled Children Who Were Why OIG Did This Review Treated for ADHD Did Not Receive Children with ADHD have higher rates of repeating grade levels, dropping Recommended Followup Care out of school, and receiving hospital Attention deficit hyperactivity disorder (ADHD) is a common neurobehavioral care. Childhood ADHD is also disorder with symptoms of inattention, hyperactivity, and impulsivity. The associated with negative outcomes in Department of Health and Human Services publishes national quality measures adulthood such as increased rates of that outline timeframes for followup care for children with ADHD. Additionally, other mental health problems, criminal professional guidelines from American Academy of Pediatrics and American behavior, and increased risk for Academy of Child and Adolescent Psychiatry describe the importance of suicide. The annual societal costs of followup care and behavioral therapy for these children. Some children may ADHD are estimated at up to not receive followup care or behavioral therapy for reasons such as limited $266 billion from loss of productivity, access to care or because practitioners may be unaware of the professional as well as spending in the healthcare, recommendations. This study focuses specifically on the extent to which justice, and educational systems. children do not receive followup services and behavioral therapy. An estimated 13 percent of What OIG Found Medicaid-enrolled children are Over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD impacted by ADHD. Treatment medication and over 3,500 children who were hospitalized with a primary involving behavioral therapy, diagnosis of ADHD did not receive followup care within the timeframes medication, and followup care can outlined in the national quality measures. Additionally, over 54,000 children did help improve these children’s not receive any behavioral therapy as recommended by professional guidelines. outcomes, long-term prognoses, and quality of life. What OIG Recommends The Office of Inspector General (OIG) recommends that the Centers for OIG conducted this review in response Medicare & Medicaid Services (CMS) work toward improving health outcomes to a congressional request to evaluate by developing strategies to increase the number of children who receive timely pharmaceutical and behavioral followup care for ADHD. We recommend that CMS accomplish this by working therapy treatment of in three ways: Medicaid-enrolled children with ADHD. Collaborate: CMS should collaborate with partners to develop strategies for improving rates of followup care for children who receive treatment for ADHD. How OIG Did This Review Assist: CMS should provide technical assistance to States to implement We reviewed Medicaid claims data, fiscal strategies for improving rates of followup care for children who receive years 2014 and 2015, from all States and treatment for ADHD. the District of Columbia for Analyze: CMS should analyze the effectiveness of strategies for improving rates Medicaid-enrolled children who received of followup care for children who receive treatment for ADHD. treatment for ADHD. We examined whether children received: (1) timely CMS concurred with all three recommendations. followup care with practitioners after being newly prescribed an ADHD medication, (2) timely followup care after ADHD hospitalizations, and (3) behavioral therapy in addition to ADHD medication. We also interviewed professionals to understand the impact ADHD has on children. Full report can be found at oig.hhs.gov/oei/reports/oei-07-17-00170.asp TABLE OF CONTENTS BACKGROUND 1 Objectives 1 Methodology 3 FINDINGS 6 Over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD medication did 6 not receive followup care within the timeframes outlined in HHS’s national quality measures Thirty-five percent of Medicaid-enrolled children who were hospitalized for ADHD did not 7 receive followup care within 30 days Nearly half of Medicaid-enrolled children who were newly prescribed an ADHD medication did 8 not receive behavioral therapy CONCLUSION AND RECOMMENDATIONS 10 CMS should collaborate with partners to develop strategies for improving rates of followup 10 care for children who receive treatment for ADHD CMS should provide technical assistance to States to implement strategies for improving rates 10 of followup care for children who receive treatment for ADHD CMS should analyze the effectiveness of strategies for improving rates of followup care for 10 children who receive treatment for ADHD Agency Comments and Office of Inspector General Response 12 APPENDICES A: Detailed Methodology 13 B: Medicaid-Enrolled Children Who Did Not Receive Followup Care After Being Newly 17 Prescribed an ADHD Medication C: Treatment for Medicaid-Enrolled Children With ADHD by Age 21 D: Medicaid-Enrolled Children Who Did Not Receive Followup Care After Hospitalization for 24 ADHD E: Medicaid-Enrolled Children Who Were Medicated for ADHD and Did Not Receive 28 Behavioral Therapy F: Agency Comments 30 ACKNOWLEDGMENTS 32 ENDNOTES 34 BACKGROUND Objectives To determine the extent to which Medicaid-enrolled children who were treated for attention deficit hyperactivity disorder (ADHD) received: 1. timely followup care with practitioners, and 2. behavioral therapy in addition to medication. Medicaid is a joint State and Federal program that provides health coverage to individuals based on eligibility criteria such as income, disability, and placement in foster care. In fiscal year (FY) 2017, nearly 37 million children were enrolled in Medicaid.1 An estimated 13 percent of children enrolled in Medicaid have been diagnosed with ADHD.2 ADHD is one of the most common neurobehavioral disorders of childhood and can affect all aspects of a child’s life, including academic achievement, well-being, and social interactions.3 Children with ADHD may experience symptoms of inattention, hyperactivity, and impulsivity, and have higher rates of repeating grade levels, dropping out of school, and receiving hospital care.4, 5 More than half of children with ADHD (60 percent) have at least one other mental health disorder.6 ADHD is associated with negative outcomes in adulthood such as increased rates of other mental health problems, criminal behavior, and increased risk for suicide.7, 8 The annual societal costs of ADHD are estimated at up to $266 billion from loss of productivity, as well as spending in the healthcare, justice, and educational systems.9 Professional Guidance on ADHD Treatment for Children Professional organizations such as the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP), along with researchers, have published a large body of guidance and information on treatment for children diagnosed with ADHD. Treatment recommendations include Food and Drug Administration-approved ADHD medication and/or evidence-based behavioral therapy (i.e., training in specific, evidence-based techniques for both the child and parent); generally, the preferred treatment is both medication and behavioral therapy.10, 11 Treatment should be individualized for each child and include followup care with a practitioner.12 Followup care includes monitoring of the child to confirm that ADHD symptoms are well controlled, that medication is effective, and that behavioral therapy and academic support needs are met.13, 14 Additionally, some children with Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 1 OEI-07-17-00170 ADHD who have complex care needs may be hospitalized and need followup care. 15 The Centers for Medicare & Medicaid Services’ Use of Quality Measures The Centers for Medicare & Medicaid Services (CMS) uses the core set of children’s healthcare quality measures for Medicaid and the Children’s Health Insurance Program (the Child Core Set), a broad set of national quality measures published by the Department of Health and Human Services (HHS), to promote improved healthcare outcomes.16 The Child Core Set measures are not clinical guidelines. CMS uses these measures to collect data about the quality of care provided to these children. The Child Core Set includes two followup care quality measures related to this evaluation: 1) when a child is newly prescribed an ADHD medication, and 2) when a child is hospitalized for mental illness.17, 18 ADHD is one of the diagnoses included in the broad range of mental health conditions assessed in the followup after hospitalization for mental illness measure. States’ reporting of these quality measures is voluntary.19, 20 The Child Core Set describes timeframes for followup visits with practitioners related to ADHD treatment. After a child is newly prescribed an ADHD medication:  an initial visit within 30 days after the prescription, and  two additional visits between 31 and 300 days after the prescription. After a child is hospitalized for mental illness, including ADHD:  a visit within 7 days after hospitalization, or  a visit no later than 30 days after hospitalization. Other Federal Agency Efforts Related to ADHD Other agencies have published work related to ADHD in children, including the Centers for Disease Control and Prevention (CDC), National Institute of Mental Health (NIMH), Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA), and the Administration for Children and Families (ACF). For example, CDC has identified treatment of ADHD in young children as a public health priority and is developing effective strategies in this area.21 Additionally, NIMH has collected data on ADHD to establish priorities for prevention, treatment, and research.22 Challenges to Providing ADHD Followup Care Professional organizations (e.g., AAP, AACAP), governmental agencies, and academic researchers have identified several challenges, which are not unique to Medicaid-enrolled children, related to ensuring that all children receive followup care for ADHD. These challenges include the following: Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 2 OEI-07-17-00170  Workforce shortages persist among many types of behavioral health practitioners (e.g., psychiatrists, psychologists, social workers, and mental health counselors).23, 24  Pediatricians and other practitioners, who may lack specialized training in diagnosing and treating behavioral health disorders, are often tasked with identifying and managing children’s behavioral health needs.25, 26  Parents and practitioners might lack awareness of current professional recommendations and the benefits of evidence-based services.27, 28  Evidence-based services may not exist in every community, and parents and practitioners may have difficulty identifying and accessing ADHD treatment consistent with professional recommendations.29  Some parents of children with ADHD are also diagnosed with ADHD and may experience challenges in consistently providing medication and behavioral interventions.30 Concerns About Medication Monitoring for Children and Related OIG Work Previous Office of Inspector General (OIG) work identified concerns related to monitoring of second-generation antipsychotics (SGAs), a class of psychotropic medications that were prescribed to children.31 Specifically, a 2015 study identified quality-of-care concerns in the medical records for 67 percent of claims for SGAs prescribed to Medicaid-enrolled children, including children diagnosed with ADHD.32 To ensure the quality of the care provided to children receiving SGAs, we recommended that CMS work with State Medicaid programs to perform utilization reviews, conduct periodic reviews of medical records, and consider other methods of enhanced oversight. CMS implemented all of these recommendations. A 2018 OIG study found that 34 percent of Medicaid-enrolled children in foster care who were prescribed psychotropic medication, including ADHD medication, did not receive treatment planning or medication monitoring.33 We recommended that ACF work to improve States’ compliance with foster care requirements related to treatment planning and medication monitoring of psychotropic medications and to assist States in strengthening these requirements. In addition, OIG received a congressional request raising concerns about treatment for Medicaid-enrolled children with ADHD and asking that OIG examine these issues. This evaluation is responsive to that request. Methodology Scope This study is limited to an evaluation of Medicaid claims data and interviews with ADHD professionals. We did not conduct medical record review or Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 3 OEI-07-17-00170 assess the quality of the treatment or accuracy of the diagnoses children received. Data Collection and Analysis We collected Medicaid Statistical Information System (MSIS) and Medicaid Management Information System (MMIS) fee-for-service claims, managed care encounters, and eligibility data for all 50 States and the District of Columbia (hereinafter, referred to as States).34, 35 These data included FYs 2014 and 2015, the most complete data available at the time of our review. We then analyzed MSIS and MMIS claims data to determine the percentages of children continuously enrolled in Medicaid who received (1) followup care with practitioners after being newly prescribed an ADHD medication, (2) followup care after hospitalizations for ADHD, and (3) behavioral therapy in addition to being newly prescribed an ADHD medication. We developed our analyses to respond to the specifics of the congressional request. We used the technical specifications established by FYs 2014 and 2015 Child Core Set measures to identify ADHD medications and hospitalizations, timeframes for followup care, and which claims are considered followup care. For the rate of followup care after hospitalization for mental illness, we analyzed only hospitalizations for ADHD.36 We added an analysis related to behavioral therapy for children treated with ADHD medication. Each analysis in the report assesses different aspects of ADHD treatment using distinct criteria; therefore, each finding reflects a different population of children. The analyses in this study are not comparable to States’ voluntary reporting on the Child Core Set. See Appendix A for additional details about our methodology. We conducted structured interviews with representatives from professional organizations who focus on the study and treatment of children with ADHD. Our interviews consisted of questions related to the impacts of ADHD on the lives of children and their families, clinical implications of inconsistent followup care, and circumstances surrounding hospitalization for ADHD. Limitations The results of our analysis are limited to the data we received. It is possible that some children received services that could not be included in our analysis (e.g., incorrect or incomplete diagnosis or procedure coding, services not paid for by Medicaid, such as school counseling).37 Therefore, this study may have underestimated the provision of services for these children. It is also possible that the population of children treated for ADHD could be underestimated if Medicaid claims data were incomplete. To the extent practicable, we conducted extensive quality assurance reviews to ensure the usability of Medicaid claims data. See Appendix A for additional details about our methodology for data validation. Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 4 OEI-07-17-00170 We conducted this study in accordance with the Quality Standards for Standards Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 5 OEI-07-17-00170 FINDINGS Over 500,000 Over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD medication did not receive followup care within the timeframes Medicaid-enrolled outlined in HHS’ national quality measures. Professional guidelines state children who were that children should have regular followup care to assess medication newly prescribed an effectiveness, identify side effects, and monitor for appropriate medication ADHD medication use when children are newly prescribed an ADHD medication. Followup care is an important part of treatment for ADHD as the disorder can affect did not receive all aspects of a child’s academic and health outcomes (e.g., increased risk of followup care within dropping out of school, substance abuse, and suicide). See Appendix B for the timeframes detailed information about the rate of followup care in each State, and Appendix C for detailed information about the rate of followup care by age. outlined in HHS’ national quality Fifty-nine percent of Medicaid-enrolled children who were newly measures prescribed an ADHD medication did not receive followup care within 30 days During our review period, 873,833 children were newly prescribed an ADHD medication, but over half did not receive followup care within 30 days. Specifically, 59 percent (516,285 children) did not receive followup care with a practitioner within 30 days as outlined in the national quality measures. Professional guidelines indicate that followup care is critical for practitioners to determine whether medication is effective (i.e., reducing ADHD symptoms and improving the child’s outcome). Followup care allows practitioners to assess children treated with ADHD medication for side effects such as changes in blood pressure and heart rate, sleep problems, tics, personality changes, irritability, and impaired growth.38, 39 Practitioners may then adjust medication as necessary. Twenty-one percent of Medicaid-enrolled children who were newly prescribed an ADHD medication did not receive 2 followup care visits within 300 days Almost a quarter of the 121,364 children who were subject to the 300-day analysis did not receive 2 followup care visits.40 Specifically, 21 percent (26,081 children) who were newly prescribed an ADHD medication did not receive 2 followup care visits between days 31 and 300, as outlined in the national quality measures. Continued followup care allows practitioners to Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 6 OEI-07-17-00170 evaluate the medication and dose to ensure that the child’s needs are met, that ADHD symptoms are improved, and that side effects are managed. Further, followup care includes close monitoring for appropriate medication use. For the 300-day analysis, we reviewed those children who were newly prescribed an ADHD medication, had a Medicaid claims history long enough to analyze their followup care for 300 days, and met other criteria (e.g., continuously eligible for Medicaid, had at least 210 days of medication).41 For more information about the different populations analyzed for different measures, see the Detailed Methodology in Appendix A. Nine percent of Medicaid-enrolled children who were newly prescribed an ADHD medication did not receive any followup care within 300 days. Of the 121,364 children who were newly prescribed an ADHD medication and were subject to the 300-day analysis, 9 percent (11,410) did not receive any followup care visits within 300 days.42 Although this measure is not included as part of the Child Core Set of national quality measures, we have included it to demonstrate the number of children who continued to receive ADHD medication in the absence of any visits with a practitioner. Followup visits are critical to ensure that a practitioner conducts ongoing assessments of medication efficacy and side effects. Additionally, some of the medications prescribed for ADHD are in a drug category with significant potential for misuse, abuse and diversion (i.e., giving away, trading, or selling of prescription medication); followup allows a practitioner to screen for these concerns.43 Thirty-five percent More than one-third of children who were hospitalized with ADHD did not receive followup care within the timeframes outlined in the national quality of Medicaid- measures.44 Specifically, 35 percent (3,694) of the 10,521 children reviewed enrolled children for this analysis did not receive followup care after hospitalization within who were 30 days. Although hospitalized for the Child ADHD did not Core Set receive followup national within 30 days quality measure Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 7 OEI-07-17-00170 does not report a separate rate of followup for each mental illness diagnosis, we analyzed the rate for ADHD admissions to demonstrate the number of children who were hospitalized for this condition and did not receive followup visits with a practitioner within 30 days. Followup care after hospitalization is essential to assess the child’s response to any treatment changes made during the hospital stay and to ensure that symptoms are managed with minimal side effects. See Appendix D for detailed information about the rate of followup care in each State. Some children with ADHD have complex care needs and other mental health conditions and may be hospitalized.45 Timely followup after hospitalization can help a child transition back to home and school and prevent hospital readmissions.46 See Appendix C for detailed information about the rate of followup care by age. Additionally, we found that 60 percent (6,560) of Medicaid-enrolled children who were hospitalized for ADHD did not receive followup care within 7 days. The national quality measure reports two rates of followup care after hospitalization for mental illness (including ADHD): within 7 days, and within 30 days. The Child Core Set reporting states that followup care after these hospitalizations should ideally include a visit within 7 days. For this review, we analyzed followup care for the 10,918 children who were hospitalized with ADHD as the primary reason. The number of children subject to the 7-day analysis is slightly higher than for the 30-day analysis because the shorter review period allowed fewer opportunities for lapses in Medicaid eligibility and hospital readmissions. Nearly half of Forty-five percent (54,726) of Medicaid-enrolled children who were newly prescribed an ADHD medication did not receive behavioral therapy during Medicaid-enrolled the 120 days prior to, and 300 days following, the new prescription. For this children who were analysis, we reviewed the 121,364 children who were subject to the 300-day newly prescribed an analysis. We used this approach to allow the greatest amount of time for at least one behavioral therapy visit before, during, or after being newly ADHD medication prescribed an ADHD medication. See Appendix E for detailed information did not receive about the rate of behavioral therapy in each State. behavioral therapy Although this rate is not reported in the Child Core Set of national quality measures, it does align with professional recommendations for ADHD treatment, namely that children receive both ADHD medication and evidence-based behavioral therapy.47, 48 Behavioral therapy could include parent training and group or individual sessions conducted over time, with activities assigned for completion between sessions.49 Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 8 OEI-07-17-00170 Through these activities, parents can learn skills and strategies to help their child succeed at school, at home, and in relationships. Behavioral therapy can also help improve children’s behavior, self-control, self-esteem, and their ability to understand how the disorder impacts their life. See Appendix C for detailed information about the rate of followup care by age. Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 9 OEI-07-17-00170 CONCLUSION AND RECOMMENDATIONS Many Medicaid-enrolled children who receive treatment for ADHD are not receiving followup care within the timeframes outlined in national quality measures and professional guidelines. Specifically, OIG found that over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD medication and over 3,500 children who were hospitalized for ADHD did not receive timely followup care as outlined in the national quality measures. Additionally, over 54,000 children did not receive any behavioral therapy as recommended by professional guidelines. Some children may not receive followup care or behavioral therapy for reasons such as limited access to care or because practitioners may be unaware of the professional recommendations. CMS is engaged in ongoing efforts related to children’s behavioral health needs (e.g., Child Core Set measures).50 Consistent with these efforts, CMS should work toward improving health outcomes by developing strategies to increase the number of children who receive followup care for ADHD. We recommend that CMS accomplish this by working in three ways: Collaborate Collaborate with partners to develop strategies for improving rates of followup care for children treated for ADHD CMS should work with professional organizations, States, and Federal agencies (e.g., CDC, NIMH, SAMHSA, HRSA, and ACF51, 52) to:  identify barriers that may inhibit children’s receipt of followup care, and  develop strategies that States can adapt for improving followup rates and promoting positive long-term outcomes for Medicaid-enrolled children. Assist Provide technical assistance to States to implement strategies for improving rates of followup care for children treated for ADHD CMS should help States implement strategies for improving rates of followup care for children treated for ADHD. This technical assistance should be accomplished through information-sharing methods such as in- person educational offerings, distance learning, or webinars. Analyze Analyze the effectiveness of strategies for improving rates of followup care for children treated for ADHD CMS should establish a plan to analyze the effectiveness of these strategies for improving rates of followup care for children treated for ADHD. CMS could accomplish this by doing the following: Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 10 OEI-07-17-00170  establishing a mechanism to continue engaging professional organizations, States, and Federal agencies to measure outcomes of these implemented strategies; and  analyzing current CMS data to assess whether the rates of ADHD followup care improve in States over time. CMS should share findings from these analyses so that States may evaluate followup rates and adjust strategies as necessary. Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care 11 OEI-07-17-00170 AGENCY COMMENTS AND OIG RESPONSE In its response to our draft report, CMS reaffirmed its commitment to providing accessible, high-quality healthcare for Medicaid-enrolled children, including those being treated for ADHD. CMS outlined some of its ongoing efforts related to children’s behavioral health needs and stated that it is committed to collaborating with States to increase the number of children who receive followup care for ADHD. CMS concurred with each of our three recommendations. Specifically, in response to our recommendation to collaborate with partners, CMS stated that it would work with various stakeholders to identify barriers to care and best practices for improving rates of followup care for children treated for ADHD. In response to our recommendation for technical assistance to States, CMS stated that it would use information gleaned from working with stakeholders, provide technical assistance to States, and share strategies that States can implement to improve rates of followup care for children treated for ADHD. Finally, in response to our recommendation to analyze the effectiveness of strategies, CMS stated that it will use publicly reported data to analyze whether efforts implemented by States have an impact on the rates of followup care for children treated for ADHD. The full text of CMS’s comments can be found in Appendix F. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 12 OEI-07-17-00170 APPENDIX A: Detailed Methodology Population Selection This study evaluates the entire population of children, aged 3–21 years, who were continuously enrolled in Medicaid, and had a claim during FYs 2014 or 2015 for either of the following: (1) a new prescription for an ADHD medication, or (2) an inpatient hospitalization with ADHD as the primary diagnosis. We used criteria from the FYs 2014 and 2015 Child Core Set technical specifications to define which medications and which hospitalizations to include in the population. Medicaid Claims Data Analysis We collected MSIS and MMIS claims and eligibility data for all 50 States and the District of Columbia for FYs 2014 and 2015. The data included eligibility information and all incurred claims (i.e., all claims that practitioners submitted) for children up to 21 years of age, enrolled in Medicaid, who had a prescription for an ADHD medication or an inpatient admission with ADHD as the principal diagnosis during the review period. New ADHD medication prescriptions. The FYs 2014 and 2015 Child Core Exhibit 1: Followup Set outlines criteria for followup care after initiating and continuing ADHD Timeline for a Newly medication. We used these criteria in the Child Core Set technical Prescribed ADHD specifications to analyze the followup rates for children who were newly Medication prescribed an ADHD medication during the review period. A new prescription for an ADHD medication is a pharmacy claim for an ADHD medication with no ADHD medication claims during the previous 120 days. For the followup rate within 300 days, the population includes only children who had at least 210 treatment days (i.e., calendar days covered with dispensed prescriptions) within the 300-day period following the new prescription. We reviewed incurred claims data for evidence of at least one followup visit with any practitioner within 30 days, and at least two followup visits within days 31 through 300 after the new ADHD medication prescription (see Exhibit 1). In the 300-day measure, the criteria allow one of the two visits to be a claim for a telephone visit. Finally, the criteria exclude any children who had a hospital stay with a mental illness primary diagnosis during the followup measure period because a hospital stay could impede their ability to receive outpatient care. To respond to the congressional request, we made some revisions to the Child Core Set technical specifications. We limited followup visits to those with mental health diagnoses to avoid including visits for unrelated medical Source: OIG methodology for determining followup rates, 2019. conditions (e.g., conjunctivitis, ear infections, influenza). We also limited the population of children reviewed to those who had a mental health diagnosis on at least one claim within the review period.53 Further, we calculated a rate for children who had no followup visits within 300 days of receiving a Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 13 OEI-07-17-00170 new ADHD medication, a rate that is not included in the Child Core Set technical specifications. Differences in number of newly medicated children reviewed. The population for the 30-day analysis was 873,833 children; the population for the 300-day analyses was 121,364 children. There are various reasons for the difference in populations. The full review period for our claims analysis was 2 years spanning October 1, 2013, through September 30, 2015. For the 30-day analysis, we reviewed new ADHD prescriptions occurring through August 31, 2015. For the 300-day analysis, we were limited to new ADHD prescriptions occurring through December 4, 2014, to allow for 300 days of followup to occur. Therefore, the 300-day analysis allowed review of fewer children over a shorter span of time. Additionally, many children were not subject to the 300-day claims analysis because they did not receive at least 210 days of ADHD medication throughout the 300-day analysis period.54 Further, children reviewed for followup within 30 days were excluded from the 300-day analysis if they were not continuously eligible for Medicaid, had a hospital admission, or turned 21 years of age. Hospitalization for ADHD. The FYs 2014 and 2015 Child Core Set outlines criteria for followup after admission for mental illness, including ADHD. We used these criteria in the Child Core Set technical specifications to analyze the followup rates specifically for children who had an inpatient admission for ADHD during the review period. We identified the population of children with a claim for an inpatient admission with the principal diagnosis of ADHD. We then analyzed incurred claims data for evidence of followup with any practitioner after the hospitalization (i.e., a claim for an outpatient visit, an intensive outpatient encounter or a partial hospitalization with a mental illness diagnosis that occurred within 7 days after discharge and within 30 days after discharge). We excluded children who had any hospital readmission during the rate measure period because hospitalization could prevent an outpatient followup visit from occurring. To respond to the congressional request, we made some revisions to the Child Core Set technical specifications. We limited followup visits to those with mental illness diagnoses to avoid including visits for unrelated medical conditions (e.g., conjunctivitis, ear infections, influenza). Differences in number of hospitalized children reviewed. The population for the 7-day analysis was 10,918 children; the population for the 30-day analysis was 10,521 children. The differences in populations for the 7-day analysis and 30-day analysis result from excluding children if they were not continuously eligible for Medicaid, had a hospital readmission, or turned 21 years of age. Behavioral therapy. There is no Child Core Set measure for behavioral therapy. Therefore, we developed criteria to calculate a behavioral therapy rate for the children who were prescribed a new ADHD medication (i.e., the 121,364 children included in the 300-day analysis). Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 14 OEI-07-17-00170 We selected the same population of children from the 300-day analysis to assess whether each child received a behavioral therapy visit before or during their treatment with ADHD medication. We used this population to allow for the greatest amount of time to identify a behavioral therapy visit prior to, during, or following the new medication prescription. These children had continuous eligibility for Medicaid, no hospital admissions that would impede behavioral therapy, and at least 210 days of medication within a 300-day period prior to turning 21 years of age. We analyzed incurred claims data for instances of behavioral therapy procedure codes that occurred within the period of 120 days before and up to 300 days after the new ADHD prescription. Because there are no specific procedure codes for evidence-based ADHD behavioral therapy, we defined behavioral therapy as those procedure codes from the technical specifications that had definitions related to psychotherapy, counseling, and behavioral health. We then searched for evidence of at least one of these visits with any practitioner. Thus, the percentage of children who received an evidence-based ADHD treatment is likely smaller than the figure we report for any behavioral therapy. Weighted analysis. For all calculations, the unit of measure was the aggregated proportion of ADHD followup care that each child received for each study measure (i.e., newly prescribed medication, behavioral therapy, and hospitalization). Children may have had more than one new ADHD prescription event or hospitalization event during our review period. When a child had more than one event in a particular measure during the review period, we weighted the results of the child’s followup visits to create an individual child statistic. The formula below demonstrates this calculation. 𝑠𝑢𝑚 𝑜𝑓 𝑒𝑣𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ𝑜𝑢𝑡 𝑓𝑜𝑙𝑙𝑜𝑤𝑢𝑝 𝑓𝑜𝑟 𝑒𝑎𝑐ℎ 𝑐ℎ𝑖𝑙𝑑 𝐼𝑛𝑑𝑖𝑣𝑖𝑑𝑢𝑎𝑙 𝑐ℎ𝑖𝑙𝑑 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 = 𝑠𝑢𝑚 𝑜𝑓 𝑎𝑙𝑙 𝑒𝑣𝑒𝑛𝑡𝑠 𝑓𝑜𝑟 𝑒𝑎𝑐ℎ 𝑐ℎ𝑖𝑙𝑑 To determine the percentage of children who received followup care, we calculated the weighted aggregate rate for each measure and then divided the sum of all individual child statistics by the total number of children. Data Validation We performed extensive data validation checks due to inherent concerns with Medicaid data quality, including:  null analysis of selected variables compared to MSIS threshold tolerances,55  month-over-month and year-over-year analysis of claims volume to assess completeness,  analysis of date variables to determine whether variables were logically ordered, and Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 15 OEI-07-17-00170  contact with State officials to inquire about data anomalies (e.g., nonsensical values, State-specific code definitions, and illogical claim volume). Through this validation process, we concluded that the data were usable for the analyses conducted for this study. Before publishing this report, we shared each State’s results with their respective State Medicaid officials. Interviews With ADHD Professionals Interview references in this report are from conversations with practitioners from professional organizations (i.e., Society for Developmental and Behavioral Pediatrics (SDBP) and the American Professional Society of ADHD and Related Disorders (APSARD)). SDBP seeks to improve the health and well-being of children and their families by supporting interdisciplinary professionals to advance the field of developmental and behavioral pediatrics. APSARD members include multidisciplinary mental health experts working to improve the quality of care for patients with ADHD through the advancement and dissemination of research and evidence-based practices. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 16 OEI-07-17-00170 APPENDIX B: Medicaid-Enrolled Children Who Did Not Receive Followup Care After Being Newly Prescribed an ADHD Medication Exhibit B-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 30 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015 Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Children Medicaid-Enrolled Children Who Did Not Who Did Not Receive a Children Who State Receive a Followup Visit Followup Visit Within Were Newly Within 30 Days After 30 Days After Being Newly Prescribed an Being Newly Prescribed Prescribed an ADHD ADHD Medication an ADHD Medication Medication Virginia 2,401 2,034 84.7% Delaware 4,674 3,815 81.6% Massachusetts 10,653 8,634 81.0% South Dakota 1,725 1,374 79.6% Idaho 5,884 4,405 74.9% Wisconsin 10,194 7,618 74.7% Oklahoma 16,557 12,131 73.3% Rhode Island 488 350 71.7% Texas 34,567 24,657 71.3% New York 9,804 6,658 67.9% Florida 65,971 43,529 66.0% North Carolina 42,398 27,563 65.0% Alabama 26,957 17,005 63.1% South Carolina 29,756 18,686 62.8% North Dakota 1,637 1,016 62.1% California 47,672 29,443 61.8% New Jersey 16,371 10,085 61.6% Tennessee 25,109 15,379 61.2% Missouri 18,055 11,021 61.0% Illinois 26,631 16,002 60.1% Colorado 11,167 6,690 59.9% Georgia 48,290 28,884 59.8% Louisiana 39,094 23,322 59.7% continued on next page Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 17 OEI-07-17-00170 Exhibit B-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 30 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015 (continued) Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Children Medicaid-Enrolled Children Who Did Not Who Did Not Receive a Children Who State Receive a Followup Visit Followup Visit Within Were Newly Within 30 Days After 30 Days After Being Newly Prescribed an Being Newly Prescribed Prescribed an ADHD ADHD Medication an ADHD Medication Medication West Virginia 4,547 2,693 59.2% NATIONAL AVERAGE 59.1% Hawaii 1,753 1,027 58.6% New Hampshire 1,425 815 57.2% Oregon 6,908 3,881 56.2% Kentucky 23,780 13,244 55.7% Michigan 31,121 17,307 55.6% Indiana 34,946 19,402 55.5% Arizona 17,851 9,841 55.1% Mississippi 18,268 9,991 54.7% Minnesota 15,880 8,599 54.1% Utah 4,573 2,460 53.8% Ohio 58,452 31,270 53.5% Washington 19,473 10,376 53.3% Iowa 10,547 5,547 52.6% Maine 4,936 2,584 52.4% Alaska 1,694 878 51.8% Nebraska 5,918 3,066 51.8% New Mexico 7,465 3,853 51.6% Nevada 4,299 2,084 48.5% Vermont 2,218 1,073 48.4% Connecticut 11,442 5,504 48.1% Wyoming 1,220 570 46.7% Maryland 8,323 3,822 45.9% Kansas 10,666 4,826 45.2% Arkansas 24,589 10,993 44.7% Pennsylvania 40,103 17,898 44.6% District of Columbia 2,311 1,027 44.4% Montana 3,070 1,353 44.1% NATIONAL TOTAL 873,833 516,285 Source: OIG analysis of Medicaid data, 2019. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 18 OEI-07-17-00170 Exhibit B-2: Medicaid-Enrolled Children Who Did Not Receive 2 Followup Care Visits Within 300 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015 Population of Number of Percentage of Medicaid-Enrolled Medicaid-Enrolled Medicaid-Enrolled Children Who Children Who Did Not Children Who Did Not State Were Newly Receive 2 Followup Visits Receive 2 Followup Visits Prescribed an Within 300 Days After Within 300 Days After ADHD Being Newly Prescribed Being Newly Prescribed Medication* an ADHD Medication an ADHD Medication Virginia 73 46 63.0% Delaware 413 258 62.5% Massachusetts 1,828 1,119 61.2% Oklahoma 5,208 2,873 55.2% Rhode Island 64 34 53.1% South Dakota 315 159 50.5% Wisconsin 1,895 940 49.6% Idaho 1,026 481 46.9% New York 1,256 554 44.1% New Hampshire 153 40 26.1% Florida 12,098 3,068 25.4% Missouri 2,640 669 25.3% North Dakota 194 47 24.2% California 5,627 1,357 24.1% Maryland 1,045 244 23.3% New Jersey 1,896 435 22.9% Texas 2,607 565 21.7% Colorado 1,697 367 21.6% NATIONAL AVERAGE 21.5% Indiana 6,129 1,311 21.4% Montana 556 119 21.4% Utah 653 137 21.0% Vermont 471 96 20.4% Oregon 447 87 19.5% North Carolina 4,581 889 19.4% Michigan 4,654 889 19.1% South Carolina 3,636 683 18.8% Iowa 1,776 330 18.6% Hawaii 110 20 18.2% Nebraska 1,057 192 18.2% Illinois 2,569 451 17.6% continued on next page Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 19 OEI-07-17-00170 Exhibit B-2: Medicaid-Enrolled Children Who Did Not Receive 2 Followup Care Visits Within 300 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015 (continued) Population of Number of Percentage of Medicaid-Enrolled Medicaid-Enrolled Medicaid-Enrolled Children Who Children Who Did Not Children Who Did Not State Were Newly Receive 2 Followup Visits Receive 2 Followup Visits Prescribed an Within 300 Days After Within 300 Days After ADHD Being Newly Prescribed Being Newly Prescribed Medication* an ADHD Medication an ADHD Medication Minnesota 2,185 371 17.0% Alaska 259 43 16.6% Wyoming 217 36 16.6% New Mexico 917 151 16.5% Ohio 5,688 912 16.0% Alabama 4,024 615 15.3% Connecticut 1,626 245 15.1% Washington 3,031 454 15.0% Nevada 422 61 14.5% Tennessee 3,993 570 14.3% West Virginia 650 92 14.2% Arizona 2,870 401 14.0% Kentucky 4,553 620 13.6% Arkansas 3,681 496 13.5% Pennsylvania 5,991 794 13.3% Louisiana 4,744 617 13.0% Maine 774 100 12.9% Georgia 4,858 584 12.0% Mississippi 2,359 272 11.5% Kansas 1,709 174 10.2% District of Columbia 139 13 9.4% NATIONAL TOTAL 121,364 26,081 Source: OIG analysis of Medicaid data, 2019. *Children were not reviewed for followup within days 31–300 if they were not continuously eligible for Medicaid, had a readmission, did not receive at least 210 days of medication, or turned 21 years of age. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 20 OEI-07-17-00170 APPENDIX C: Treatment for Medicaid-Enrolled Children With ADHD by Age Exhibit C-1: Percentage of Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 30 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015, by Age Source: OIG analysis of Medicaid data, 2019. Exhibit C-2: Percentage of Medicaid-Enrolled Children Who Did Not Receive 2 Followup Care Visits Within 300 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015, by Age Source: OIG analysis of Medicaid data, 2019. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 21 OEI-07-17-00170 Exhibit C-3: Percentage of Medicaid-Enrolled Children Who Did Not Receive Any Followup Care Within 300 Days After Being Newly Prescribed an ADHD Medication, FYs 2014–2015, by Age Source: OIG analysis of Medicaid data, 2019. Exhibit C-4: Percentage of Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 30 Days After Hospitalization for ADHD, FYs 2014–2015, by Age Source: OIG analysis of Medicaid data, 2019. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 22 OEI-07-17-00170 Exhibit C-5: Percentage of Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 7 Days After Hospitalization for ADHD, FYs 2014–2015, by Age Source: OIG analysis of Medicaid data, 2019. Exhibit C-6: Percentage of Medicaid-Enrolled Children Who Were Medicated for ADHD and Did Not Receive Behavioral Therapy, FYs 2014–2015, by Age Source: OIG analysis of Medicaid data, 2019. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 23 OEI-07-17-00170 APPENDIX D: Medicaid-Enrolled Children Who Did Not Receive Followup Care After Hospitalization for ADHD Exhibit D-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 30 Days After Hospitalization for ADHD, FYs 2014–2015 Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Children Medicaid-Enrolled Children Who Were Who Were Hospitalized for State Children Who Were Hospitalized for ADHD ADHD Who Did Not Receive Hospitalized for Who Did Not Receive a a Followup Visit Within 30 ADHD* Followup Visit Within 30 Days Days Delaware** -- -- 100.0% Rhode Island** -- -- 100.0% Virginia 23 19 82.6% Idaho 25 20 80.0% Massachusetts 14 11 78.6% South Dakota 140 103 73.6% New York 1,101 747 67.8% Colorado** -- -- 63.6% Montana 19 12 63.2% North Carolina 316 189 59.8% Oklahoma 21 12 57.1% Florida 1,095 531 48.5% North Dakota** -- -- 47.1% New Mexico 64 28 43.8% New Hampshire** -- -- 40.0% New Jersey 410 164 40.0% Kentucky 176 66 37.5% NATIONAL AVERAGE 35.1% Arizona 72 25 34.7% Maine 139 48 34.5% Alabama 529 178 33.6% Wyoming** -- -- 33.3% Mississippi 611 199 32.6% Alaska 233 76 32.6% Georgia 53 16 30.2% South Carolina 159 47 29.6% continued on next page Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 24 OEI-07-17-00170 Exhibit D-1: Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 30 Days After Hospitalization for ADHD, FYs 2014–2015 (continued) Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Children Medicaid-Enrolled Children Who Were Who Were Hospitalized for State Children Who Were Hospitalized for ADHD ADHD Who Did Not Receive Hospitalized for Who Did Not Receive a a Followup Visit Within 30 ADHD* Followup Visit Within 30 Days Days Tennessee 136 40 29.4% Connecticut 98 28 28.6% West Virginia 363 101 27.8% Maryland 641 176 27.5% Louisiana 48 13 26.5% Arkansas 178 46 25.7% Hawaii** -- -- 25.0% Indiana 204 50 24.4% Wisconsin 207 50 24.0% Texas 280 66 23.6% California 96 22 22.9% Nebraska 133 30 22.6% Nevada 126 28 22.0% Missouri 493 108 21.9% Minnesota 221 47 21.3% District of Columbia 122 26 21.1% Illinois 149 31 20.7% Ohio** -- -- 20.0% Pennsylvania 1,227 238 19.4% Michigan 67 12 17.6% Kansas 80 12 14.8% Iowa 345 48 13.9% Washington** -- -- 7.7% Oregon** -- 0 0.0% Utah** -- 0 0.0% Vermont** -- 0 0.0% NATIONAL TOTAL 10,521 3,694 Source: OIG analysis of Medicaid data, 2019. *Children were not reviewed for followup 30 days after hospitalization for ADHD if they were not continuously eligible for Medicaid, had a readmission, or turned 21 years of age. **To protect privacy, values of 1 to 10 are not reported. Additionally, values that allow a value of 1 to 10 to be derived are also not reported. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 25 OEI-07-17-00170 Exhibit D-2: Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 7 Days After Hospitalization for ADHD, FYs 2014–2015 Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Children Medicaid-Enrolled Children Who Were Who Were Hospitalized for State Children Who Were Hospitalized for ADHD ADHD Who Did Not Receive Hospitalized for Who Did Not Receive a a Followup Visit Within 7 ADHD Followup Visit Within 7 Days Days Delaware** -- -- 100.0% Rhode Island** -- -- 100.0% South Dakota 145 129 88.4% Virginia 23 20 87.0% Oklahoma 22 19 86.4% Montana 20 17 85.0% North Carolina 330 274 83.0% New York 1,149 944 82.2% Colorado** -- -- 81.8% New Mexico 69 56 81.2% Idaho 25 20 80.0% Massachusetts 14 11 78.6% Wyoming 14 11 78.6% Florida 1,151 827 71.9% New Jersey 436 294 67.4% Mississippi 630 423 67.1% West Virginia 377 252 66.8% Hawaii** -- -- 66.7% Alabama 542 348 64.2% Kentucky 182 115 63.2% North Dakota 19 12 63.2% New Hampshire** -- -- 60.0% NATIONAL AVERAGE 60.0% Texas 289 173 59.9% Maine 141 84 59.6% Arkansas 186 110 58.8% Alaska 242 141 58.3% Illinois 158 90 57.0% Ohio** -- -- 56.3% South Carolina 164 90 54.9% Maryland 659 359 54.5% Tennessee 140 76 54.3% continued on next page Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 26 OEI-07-17-00170 Exhibit D-2: Medicaid-Enrolled Children Who Did Not Receive Followup Care Within 7 Days After Hospitalization for ADHD, FYs 2014–2015 (continued) Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Children Medicaid-Enrolled Children Who Were Who Were Hospitalized for State Children Who Were Hospitalized for ADHD ADHD Who Did Not Receive Hospitalized for Who Did Not Receive a a Followup Visit Within 7 ADHD Followup Visit Within 7 Days Days Connecticut 103 54 51.9% Nevada 131 64 48.5% Indiana 213 103 48.4% Georgia 56 27 48.2% Arizona 79 38 48.1% Wisconsin 222 107 48.0% Missouri 520 244 46.9% Minnesota 223 103 46.2% Nebraska 135 61 45.2% Pennsylvania 1,252 544 43.5% Kansas 87 38 43.2% Louisiana 49 21 42.0% District of Columbia 123 52 41.9% Michigan 69 26 37.7% California 98 36 36.4% Oregon** -- -- 30.8% Washington** -- -- 30.8% Iowa 351 107 30.5% Utah** -- 0 0% Vermont** -- 0 0% NATIONAL TOTAL 10,918 6,560 Source: OIG analysis of Medicaid data, 2019. **To protect privacy, values of 1 to 10 are not reported. Additionally, values that allow a value of 1 to 10 to be derived are also not reported. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 27 OEI-07-17-00170 APPENDIX E: Medicaid-Enrolled Children Who Were Medicated for ADHD and Did Not Receive Behavioral Therapy Exhibit E-1: Medicaid-Enrolled Children Who Were Medicated for ADHD and Did Not Receive Behavioral Therapy, FYs 2014–2015 Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Medicaid-Enrolled Children Who Were Children Who Were State Children Who Were Medicated for ADHD Medicated for ADHD Who Medicated for Who Did Not Receive Did Not Receive ADHD* Behavioral Therapy Behavioral Therapy Massachusetts 1,828 1,642 89.8% Idaho 1,026 804 78.4% Virginia 73 53 72.6% South Dakota 315 216 68.6% Florida 12,098 7,755 64.1% South Carolina 3,636 2,149 59.1% North Carolina 4,581 2,658 58.0% New York 1,256 709 56.4% Wisconsin 1,895 1,053 55.6% Louisiana 4,744 2,583 54.4% North Dakota 194 102 52.6% Texas 2,607 1,306 50.1% Washington 3,031 1,463 48.3% Missouri 2,640 1,264 47.9% New Jersey 1,896 905 47.7% Alabama 4,024 1,833 45.6% Delaware 413 187 45.3% NATIONAL AVERAGE 45.1% Tennessee 3,993 1,789 44.8% Utah 653 292 44.7% Oklahoma 5,208 2,324 44.6% Colorado 1,697 752 44.3% Indiana 6,129 2,673 43.6% Illinois 2,569 1,117 43.5% continued on next page Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 28 OEI-07-17-00170 Exhibit E-1: Medicaid-Enrolled Children Who Were Medicated for ADHD and Did Not Receive Behavioral Therapy, FYs 2014–2015 (continued) Number of Percentage of Population of Medicaid-Enrolled Medicaid-Enrolled Medicaid-Enrolled Children Who Were Children Who Were State Children Who Were Medicated for ADHD Medicated for ADHD Who Medicated for Who Did Not Receive Did Not Receive ADHD* Behavioral Therapy Behavioral Therapy Michigan 4,654 1,962 42.1% Georgia 4,858 2,039 42.0% Kentucky 4,553 1,897 41.7% California 5,627 2,329 41.4% Oregon 447 183 40.8% Rhode Island 64 26 40.6% New Hampshire 153 62 40.5% West Virginia 650 261 40.2% Alaska 259 100 38.6% Ohio 5,688 2,173 38.2% Maine 774 287 37.1% Nevada 422 149 35.3% Mississippi 2,359 815 34.5% Hawaii 110 36 32.7% Connecticut 1,626 529 32.5% Wyoming 217 69 31.8% Arkansas 3,681 1,136 30.9% Minnesota 2,185 674 30.8% Iowa 1,776 530 29.8% Montana 556 158 28.4% Vermont 471 131 27.8% Nebraska 1,057 293 27.7% New Mexico 917 254 27.7% Pennsylvania 5,991 1,626 27.1% Kansas 1,709 438 25.6% Maryland 1,045 251 24.0% District of Columbia 139 32 23.0% Arizona 2,870 657 22.9% NATIONAL TOTAL 121,364 54,726 Source: OIG analysis of Medicaid data, 2019. *Children were not reviewed for behavioral therapy if they were not continuously eligible for Medicaid, had a readmission, did not receive at least 210 days of medication, or turned 21 years of age. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 29 OEI-07-17-00170 APPENDIX F: Agency Comments Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 30 OEI-07-17-00170 Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 31 OEI-07-17-00170 ACKNOWLEDGMENTS Jamila Murga served as the team leader for this study, and Abbi Warmker served as lead analyst. Others in the Office of Evaluation and Inspections who conducted the study include Katharine Fry, Anna Pechenina, Dana Squires, and Andrea Staples. Office of Evaluation and Inspections central office staff who provided support include Clarence Arnold, Eddie Baker, Jr., and Kevin Manley. Other Office of Inspector General staff who provided support include Erin Fratangelo, Scott Frederixon, Gus George, Logan Kingma, Art Livingston, Ann Lowe, Conswelia McCourt, Jim Rodgers, Jessica Swanstrom, and Michael Willey. This report was prepared under the direction of Brian T. Whitley, Regional Inspector General for Evaluation and Inspections in the Kansas City regional office, and Jennifer E. King, Deputy Regional Inspector General. To obtain additional information concerning this report or to obtain copies, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. Over Half of Medicaid-Enrolled Children Treated for ADHD Did Not Receive Recommended Care 32 OEI-07-17-00170 ABOUT THE OFFICE OF INSPECTOR GENERAL The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nation-wide network of audits, investigations, and inspections conducted by the following operating components: Office of Audit The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit Services work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable and Inspections information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations. Office of The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, Investigations operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. Office of Counsel to The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and the Inspector operations and providing all legal support for OIG’s internal operations. General OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the healthcare industry concerning the anti-kickback statute and other OIG enforcement authorities. 33 ENDNOTES 1 CMS, “FY 2017 Children’s Enrollment Report.” Accessed at https://www.medicaid.gov/chip/downloads/fy-2017-childrens- enrollment-report.pdf on December 26, 2018. 2 Danielson, et al., “Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016.” Journal of Clinical Child and Adolescent Psychology, pp. 1–14. 3 American Academy of Pediatrics (AAP), “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” Pediatrics, Vol. 128, No. 5, November 2011. Accessed at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 17, 2016. 4 Visser, et al., “Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2–5 Years—United States, 2008–2014,” Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016. Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 5 Untreated adolescents with ADHD have higher rates of risky sexual behaviors, suicidal thoughts in college, incarcerations, automobile accidents, and medical burdens. Brahmbhatt, et al., “Diagnosis and Treatment of ADHD during Adolescence in the Primary Care Setting: Review and Future Directions,” Journal of Adolescent Health, Vol. 59, No. 2, August 2016. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576000/ on May 14, 2019. 6 Centers for Disease Control and Prevention (CDC) “Attention-Deficit/Hyperactivity Disorder and Psychiatric Comorbidity: Functional Outcomes in a School-Based Sample of Children.” Accessed at https://www.cdc.gov/ncbddd/adhd/features/adhd- keyfindings-psychiatric-comorbidity-school-children.html on May 6, 2019. 7 Visser, et al., “Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2–5 Years—United States, 2008–2014,” Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016. Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 8 Fletcher, et al., “Long-term Consequences of Childhood ADHD on Criminal Activities,” Journal of Mental Health Policy Economics, Vol 12, No. 3, September 2009, pp. 119–138. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398051/pdf/nihms386784.pdf on April 15, 2019. 9 Doshi, et al., “Economic Impact of Childhood and Adult Attention-Deficit/Hyperactivity Disorder in the United States,” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 51, No. 10, pp. 990–1002, October 2012. 10 AAP, “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” Pediatrics, Vol. 128, No. 5, November 2011. Accessed at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 17, 2016. 11 Centers for Disease Control and Prevention (CDC), “Behavior therapy for young children with ADHD.” Accessed at https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html on November 16, 2018. 12 AACAP, “Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder,” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 46, No. 7, July 2007. Accessed at https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/jaacap_adhd_2007.pdf on January 10, 2018. 13 Ibid. 14 AAP, “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” Pediatrics, Vol. 128, No. 5, November 2011. Accessed at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 15 Although ADHD is not typically the primary reason for inpatient admissions, the disorder is often listed as one of the health conditions treated during children’s hospital stays. For hospitalizations with any mental health diagnosis in children ages 3-20 years, ADHD was one of the most commonly listed health conditions treated during the hospitalization. Specifically, ADHD was one of the diagnoses in 19 percent of hospitalizations in general hospitals (i.e., those that serve adults and children) and 23 percent of hospitalizations in children’s hospitals (i.e., those that serve children only). This finding suggests that ADHD may contribute to factors (e.g., accidents, medical nonadherence) that lead to hospitalization. Bardach, et al., “Common and Costly Hospitalizations for Pediatric Mental Health Disorders,” Pediatrics, Vol. 133, No. 4, April 2014. Accessed at http://pediatrics.aappublications.org/content/early/2014/03/11/peds.2013-3165 on December 16, 2016. 16 The Child Core Set was developed as a requirement of Section 401 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), P.L. No. 111-3 (Feb. 4, 2009). Accessed at https://www.gpo.gov/fdsys/pkg/PLAW-111publ3/pdf/PLAW- 111publ3.pdf on November 22, 2016. 17 The first measure includes the percentage of children who were newly prescribed an ADHD medication who had at least two followup visits within a 10-month period. Two rates are reported: (1) the percentage of children who had one followup visit with a 34 practitioner within 30 days; (2) the percentage of children who had at least two followup visits within 300 days. The second measure includes the percentage of discharges for children 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner. The Child Core Set measure reports the followup after hospitalization rate for all mental illness diagnoses in aggregate. ADHD is one of the diagnoses included in the hospitalization measure. The followup timeframes outlined in this measure were not developed specifically for ADHD hospitalizations, but rather for any hospitalization for the broad range of mental illnesses. Two rates are reported: (1) the percentage of children who received followup within 7 days of discharge; (2) the percentage of children who received followup within 30 days of discharge. CMS, 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP, Chart Pack (August 2016), pp. 49-55. Accessed at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-chart-pack.pdf on November 29, 2016. 18 The Child Core Set measure establishes an ADHD medication list which includes all drugs indicated for ADHD; it is possible children were prescribed these medications for other indications. We used the list exactly as defined in the Child Core Set measure to identify the population of children who were newly prescribed an ADHD medication. 19 There are several limitations to voluntary data reporting. States may not always adhere to technical specifications when reporting, or include different populations in the measures (i.e., Medicaid versus CHIP). Additionally, not all States submit data because reporting is voluntary. The Department of Health and Human Services (HHS), 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP. Accessed at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec- rept.pdf on November 11, 2016. 20 Recent legislation will require States’ mandatory reporting beginning fiscal year 2024. P.L. 115-123 § 50102. Accessed at https://www.congress.gov/bill/115th-congress/house-bill/1892/text on December 18, 2018. 21 CDC has identified treatment of ADHD in young children as a public health priority that has the potential for large-scale, positive impact in a relatively short amount of time. Therefore, the agency has applied their Winnable Battles approach to this high-priority area, using known effective strategies to address it. CDC uses the Winnable Battles approach for certain public health challenges to identify priority strategies, define clear targets, and work closely with public health partners, to make significant progress in reducing the health burden from diseases and conditions. The Winnable Battles approach enabled the treatment of ADHD program in CDC’s National Center on Birth Defects and Developmental Disabilities to garner agency-wide leadership support and collaboration to refine and advance its work on this initiative to promote impact. Accessed at https://www.cdc.gov/winnablebattles/report/docs/winnable-battles-final-report.pdf on March 11, 2019. 22 NIMH has collected data on the prevalence and distribution of ADHD to establish resource allocation priorities for prevention, treatment and research. Merikangas, et al. “Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A),” Journal of American Academy of Child Adolescent Psychiatry. Vol 49, No 10, October 2010. Accessed at https://www.ncbi.nlm.nih.gov/pubmed/20855043 on January 24, 2019. 23 HHS Health Resources and Services Administration, National Projections of Supply and Demand for Selected Behavioral Health Practitioners: 2013-2025. Accessed at https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce- analysis/research/projections/behavioral-health2013-2025.pdf on September 19, 2018. 24 In 2012, there were approximately 8,300 practicing child and adolescent psychiatrists in the country. Children in rural areas and areas of low socioeconomic status had significantly reduced access. The national child and adolescent psychiatrist to per youth was 12.9 to 100,000. AACAP, Child and Adolescent Psychiatry Workforce Crisis: Solutions To Improve Early Intervention and Access to Care. Accessed at https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_brochure_2013.pdf on January 23, 2018. 25 Reimbursement for practitioners who provide recommended ADHD care may not be proportionate to their services since this condition requires more time than other conditions they typically address. For example, recommended ADHD care requires that practitioners spend more time with patients and families, developing contacts with school personnel, and providing continuous, coordinated care than for other conditions. AAP, “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” Pediatrics, Vol. 128, No. 5, November 2011. Accessed at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 26 An AAP survey assessed pediatricians’ perception of availability of mental health services in the community, the extent of their mental health education and their interest in future education in this area. When asked to name barriers to treatment or referral of mental health problems for children, pediatricians listed the following: lack of training in mental health treatment (70 percent), lack of competence in ability to diagnose mental health problems (65 percent), lack of confidence in ability to treat mental health problems with medication (64 percent), lack of time to treat mental health problems (80 percent), long waiting periods for referred mental health providers (79 percent), inadequate reimbursement for treatment (54 percent), unfamiliarity with procedure codes that reimburse for treatment (49 percent). AAP, Periodic Survey #59 Identification, Management, and Referral for Patient Mental Health Problems and Maternal Depression. Accessed at https://www.aap.org/en-us/professional- 35 resources/Research/Pages/PS59_Executive_Summary_IdentificationManagementandReferralforPatientMentalHealthProblems.aspx on March 11, 2019. 27 Visser, et al., “Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2–5 Years—United States, 2008–2014,” Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016. Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 28 Research has identified inconsistencies in pediatricians’ ADHD care practices when compared to professional guidelines. Specifically, a 2014 study that conducted chart review of a random sample of 1,594 medical records across 188 pediatricians at 50 different practices found approximately 90 percent of pediatricians did not use parent and teacher rating scales to monitor treatment response and side effects despite AAP consensus recommendations to do so. Additionally, the study found that only half of children evaluated for ADHD received an evidence-based assessment and diagnosis. Epstein, et al., “Variability in ADHD Care in Community-Based Pediatrics,” Pediatrics. Vol. 134, No. 6, September 2014. Accessed at www.pediatrics.org/cgi/doi/10.1542/peds.2014-1500 on January 8, 2018. 29 Visser, et al., “Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2–5 Years—United States, 2008–2014,” Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016. Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 30 AAP, “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” Pediatrics, Vol. 128, No. 5, November 2011. Accessed at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 31 OIG, Second-Generation Antipsychotic Drug Use Among Medicaid-Enrolled Children: Quality-of-Care Concerns, OEI-07-12-00320, March 2015. Accessed at https://oig.hhs.gov/oei/reports/oei-07-12-00320.asp on March 26, 2019. 32 The sample was selected using Medicaid-paid claims for SGAs including aripiprazole, clozapine, lurasidone, iloperidone, asenapine, olanzapine, paliperidone, quetiapine fumarate, risperidone, and ziprasidone. None of these were considered an ADHD medication in the current study. 33 OIG, Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication, OEI-07-15-00380, September 2018. Accessed at https://oig.hhs.gov/oei/reports/oei-07-15-00380.asp on March 11, 2019. 34 MSIS is the system in which CMS collects all Medicaid claims and related data from all States. 35 MMIS are the State-specific systems to collect and process Medicaid claims. MMIS data systems are not validated by CMS. See the Detailed Methodology for more information on our process for validating these data. 36 We analyzed children hospitalized with a primary diagnosis of ADHD. These children may have had additional diagnoses that contributed to their need for hospitalization. 37 Additionally, Medicaid reimbursement policy differs among States. It is possible that guidelines on criteria for admission and for hospital services may have varied. These variations may have impacted the claims that were used to identify the population and determine followup rates. 38 Visser, et al., “Vital Signs: National and State-Specific Patterns of Attention Deficit/Hyperactivity Disorder Treatment Among Insured Children Aged 2–5 Years—United States, 2008-2014,” Morbidity and Mortality Weekly Report, Vol. 65, No. 17, May 2016. Accessed at https://www.cdc.gov/mmwr/volumes/65/wr/mm6517e1.htm on December 16, 2016. 39 AACAP, “Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention Deficit/Hyperactivity Disorder,” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 46, No. 7, July 2007. Accessed at https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/jaacap_adhd_2007.pdf on January 10, 2018. 40 Children were not reviewed for followup within days 31–300 if they were not continuously eligible for Medicaid, had a readmission, did not receive at least 210 days of medication, or turned 21 years of age. Therefore, the population of the 300-day analysis differs from the population of the 30-day analysis. 41 Research shows that Medicaid-enrolled children often discontinue ADHD medication treatment over time. Charach and Fernandez, “Enhancing ADHD Medication Adherence: Challenges and Opportunities.” Current Psychiatry Reports. 2013; 15(7): 371. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718998/ on March 1, 2019. 42 Children were not reviewed for followup within 300 days if they were not continuously eligible for Medicaid, had a readmission, did not receive at least 210 days of medication, or turned 21 years of age. Therefore, the population of this analysis differs from the population of the 30-day analysis. 43 Harstad, et al., “ADHD: Attention-Deficit/Hyperactivity Disorder and Substance Abuse,” Pediatrics, Vol. 134, No. 1, July 2014. Accessed at http://pediatrics.aappublications.org/content/pediatrics/134/1/e293.full.pdf on March 11, 2019. 44 Children were not reviewed for followup within 30 days if they were not continuously eligible for Medicaid, had a readmission, or turned 21 years of age. Therefore, the population of the 30-day analysis differs from the population of the 7-day analysis. 45 Bardach, et al., “Common and Costly Hospitalizations for Pediatric Mental Health Disorders,” Pediatrics, Vol. 133, No. 4, April 2014. Accessed at http://pediatrics.aappublications.org/content/early/2014/03/11/peds.2013-3165 on December 16, 2016. 46 HHS, 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP. Accessed at 36 https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec-rept.pdf on November 29, 2016. 47 AAP, “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” Pediatrics, Vol. 128, No. 5, November 2011. Accessed at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654 on November 7, 2016. 48 Centers for Disease Control and Prevention (CDC), “Behavior therapy for young children with ADHD.” Accessed at https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html on November 16, 2018. 49 CDC, “Behavior therapy for young children with ADHD.” Accessed at https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html on November 16, 2018. 50 CMS has collaborated with multiple divisions within HHS, including ACF, FDA, and SAMHSA, on behavioral health issues. For example, these agencies work together to strengthen oversight and monitoring of psychotropic medications for Medicaid-enrolled children. Accessed at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf on April 24, 2016. 51 ACF is responsible for the oversight of child welfare programs, including foster care. 52 Researchers examined Medicaid outpatient and prescription drug claims from 2011 from multiple states and found that more than 1 in 4 children between the ages of 2 and 17 years who were in foster care had received an ADHD diagnosis. Additionally, children with ADHD who were in foster care were also more likely to have another mental health disorder simultaneously (e.g., oppositional defiant disorder, depression, or anxiety). These findings show a substantial need for medical and behavioral services within this group. Abstract presentation of "The Diagnosis and Treatment of ADHD among Children in Foster Care Using Medicaid Claims Data,” by Melissa Danielson, CDC statistician, at the American Academy of Pediatrics Experience conference, October 26, 2015. Accessed at https://aap.confex.com/aap/2015/webprogram/Paper30570.html on March 11, 2019. 53 Some ADHD medications can also be used to treat medical conditions (e.g., hypertension and narcolepsy). To exclude those children who were prescribed ADHD medications for a medical condition, we excluded from our analysis children who did not have at least one claim with a mental illness diagnosis and children under 3 years of age. 54 This decrease is consistent with research that shows Medicaid-enrolled children often discontinue ADHD medication treatment over time. Some reasons for discontinuation can include side effects, ineffective medication or dosage, and lack of social supports. Charach and Fernandez, “Enhancing ADHD Medication Adherence: Challenges and Opportunities,” Current Psychiatry Reports, 2013; 15(7): 371. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718998/ on March 1, 2019. 55 MSIS threshold error tolerances allow between 0.1 and 5.0 percent missing, unknown, or invalid codes for the variables used in this analysis. CMS, MSIS File Specifications and Data Dictionary, 2012. Accessed at https://www.cms.gov/Research-Statistics-Data- and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MSIS-Data-Dictionary-2012.pdf on February 5, 2018. 37