Original Paper

Maternal and Child Health Journal

, Volume 10, Issue 5, pp 461-466

Children Who Are Medically Fragile in North Carolina: Using Medicaid Data to Estimate Prevalence and Medical Care Costs in 2004

  • Paul A. BuescherAffiliated withState Center for Health Statistics, North Carolina Division of Public Health Email author 
  • , J. Timothy WhitmireAffiliated withState Center for Health Statistics, North Carolina Division of Public Health
  • , Susan BrunssenAffiliated withSchool of Nursing, University of North Carolina at Chapel Hill
  • , Catherine E. Kluttz-HileAffiliated withChildren and youth Branch, North Carolina Division of Public Healthe

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Objectives: The purpose of this paper is to demonstrate a method of using medical insurance paid claims and enrollment data to estimate the prevalence of selected health conditions in a population and to profile associated medical care costs. The examples presented here use North Carolina Medicaid data to produce estimates for children ages 0–19 who are medically fragile. These children with serious health conditions are a small subset of all children with special health care needs. Methods: The children who are medically fragile were identified through selected procedure and durable medical equipment codes. We profiled the expenditures for all medical services provided to these children during 2004. Results: 1,914 children ages 0–19 enrolled in Medicaid were identified as medically fragile (0.22 percent). The amount paid by Medicaid for these children during 2004 for all medical services was $133.8 million, or $69,906 per child. By comparison, the average expenditure by Medicaid during 2004 for a randomly selected group of children receiving well-child care visits was $3,181 per child. The $133.8 million of Medicaid expenditures for the children who are medically fragile represents 6.8 percent of the nearly $2 billion spent by Medicaid in 2004 for all medical services for all children ages 0–19. Conclusions: This study presents a standard methodology to identify children with specific health conditions and describe their medical care costs. Our example uses Medicaid claims and enrollment data to measure prevalence and costs among children who are medically fragile. This approach could be replicated for other health care payer data bases and also in other geographic areas.


Children with special health care needs Medically fragile children Medical care costs Medicaid Population prevalence