Continuities in Health Care Utilization Among Children Placed in Foster Care

Background and Purpose:  The U.S. Department of Health and Human Services is increasingly focused on the well-being of children who touch the child welfare system.  The shift in focus is evident in myriad ways including the emphasis on life course outcomes for youth aging out of foster care, continuity of educational experience when children are placed, and trauma informed cognitive behavioral interventions for victims of maltreatment.

Although the emphasis on child well-being, broadly defined, is welcome, the fact is there is very little known about the status of children before, during, and after contact with the child welfare system.  The lack of understanding is particularly acute in the area of health care.  For example, among children who are eligible for Medicaid prior to placement, does utilization of health care utilization change as a result of placement?  There is reason to believe utilization does change, but it is not known whether this is a general effect or limited to children with pre-existing conditions, children from one part of a state, or children placed in family vs. institutional care.  Our study addresses these fundamental questions.

Methods:  We use linked administrative data to examine health care claims on behalf of children prior to, during, and after placement into out-of-come care.  The sample includes nearly 75,000 children placed for the first time between 2005 and 2011.  Claims data include the cost of care, diagnosis codes, and procedure codes.  The methods used are largely descriptive.  We aggregate all claims prior to the first placement and then disaggregate those claims into those incurred in the three months prior to placement.  We then aggregate the claims data for each month of placement and calculate the average cost per child-month during the 1st through 12^th month of placement.  These data are then compared with pre-placement claims to draw conclusions about continuity in health care utilization and costs pursuant to placement.  Finally, the data are disaggregated by pre-placement mental health service use, type of placement, and region of state to assess whether there are differential effects associated with pre-existing mental health conditions, placement type, and geography.

Results:  Our results indicate that there are important changes in health care utilization for children placed in foster care.  Overall, health care utilization increases once a child enters foster care, especially for children and young people with pre-existing mental health conditions.  Geographic variation suggests that features of the health care system may influence what happens to health care utilization once a child enters care.

Conclusions and Implications:  To the extent there are changes in health care utilization as a result of placement, it is important to understand those changes in the broader context of child well-being.  Continuity of care also has important implications for health care coverage.  States are actively engaged in reforms that will change how health care is financed.  Patterns of health care utilization before and during placement have to be understood if sufficient resources are to be set aside for children once they enter foster care.