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Pediatrics. 2017 Sep;140(3). pii: e20171095. doi: 10.1542/peds.2017-1095. Epub 2017 Aug 1.

High-Expenditure Pharmaceutical Use Among Children in Medicaid.

Author information

Department of Pediatrics and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario;
Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario.
Children's Hospital Association, Lenexa, Kansas.
Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia.
Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, and Department of Pediatrics, School of Medicine, Stanford University, Stanford, California.
Division of General Pediatrics, Philip R. Lee Institute for Health Policy Studies, Department of Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California.
UCLA-Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; and.
Division of General Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.



Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications.


Retrospective, cross-sectional study of 3 271 081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013.


Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes.


Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.

[Indexed for MEDLINE]
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Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: Dr Cohen is a member of the Committee to Evaluate Drugs which provides advice to Ontario's Ministry of Health and Long-Term Care on public drug policy. This Canadian governmental ministry had no role in the design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review, or approval of the manuscript; or the decision to submit for publication. The views herein are solely those of the authors; the other authors have indicated they have no potential conflicts of interest to disclose.

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