The Americans with Disabilities Act: implications for managed care for persons with mental illness and addiction disorders

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration, examines the Americans with Disabilities Act ("the ADA") and its application to managed care. The ADA provides important protections for persons with disabilities who are members of managed care arrangements, regardless of whether their membership is sponsored by an employer, Medicare, or Medicaid or is purchased privately. The interaction between the ADA and managed care is complex, and different issues can arise under publicly and privately sponsored plans.

Hereditary postlingual sensorineural hearing loss mapping to chromosome Xq21

BACKGROUND

Mutations on the X-chromosome clinically manifesting different phenotypes of hearing loss have been mapped to the long arm at different loci, DFN1-DFN3. Another defect in a family with sex-linked, postlingual, progressive sensorineural hearing loss was mapped to Xq.

METHODS

Clinically, the family was evaluated by physical and audiometric examination of 17 members including computerized tomographic (CT) evaluation of the proband. Molecular evaluation consisted of polymerase chain reaction amplification of patient genomic DNA and resolution 32P-labeled fragments by polyacrylamide gels. Inheritance of DNA alleles and deafness were analyzed using the MLINK computer program.

RESULTS

Five affected males demonstrated symmetrical sensorineural hearing loss as significant as 100 decibels (dB). Two carrier females had a milder loss with frequency findings of 10 dB to 60 dB. Computerized tomography (CT) evaluation of the temporal bones of the proband was normal. The odds were 200:1 that the responsible gene was linked to locus DXS986 (maximum lod score = 2.3 at 0 = 0). Analysis of recombination events defined by family members demonstrates that the responsible gene lies in a 21 cM (30 MB) interval, between loci DXS12175 and 1106. The disease locus in this family does not appear to map to DFN1 or DFN3.

CONCLUSION

The family described here, with affected males who have progressive, postlingual sensorineural hearing loss and mildly affected females maps most compatibly to the DFN2 locus. Analysis of hereditary deafness in this family refines the DFN2 locus to a 9.2 Mb region in chromosome X band q21 between DXS990 and DXS106.

The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery

Patients undergoing vascular surgery have a high risk of suffering major postoperative cardiac events. Preoperative myocardial ischemia as detected by Holter monitoring identifies a high-risk subgroup whose postoperative ischemia, similarly detected, seems to herald major cardiac events. In this study, we determined whether systematic, patient-specific postoperative heart rate control with beta-adrenergic blocker therapy decreases the incidence of postoperative ischemia among high-risk vascular surgery patients. A total of 26 of 150 patients who underwent elective vascular surgery and were monitored preoperatively by 24-h Holter were found to have significant myocardial ischemia as defined by ST-segment depression. The minimal heart rate at which this ST-segment depression occurred was identified (ischemic threshold), and these 26 patients were then randomized to receive continuous i.v. beta-blockade with esmolol or placebo plus usual medical therapy, aiming to reduce the postoperative heart rate to 20% below the ischemic threshold. All patients were monitored by Holter for 48 h postoperatively. Postoperative Holter readings were analyzed for the incidence of ischemia and for the number of hours during which heart rate was controlled below the ischemia threshold. Patients had a median of two episodes of preoperative ischemia lasting a median of 30 min (range 1-155 min). A total of 15 patients were randomized to receive esmolol, and 11 were randomized to receive placebo. The two groups were comparable with respect to clinical characteristics and incidence and duration of preoperative ischemia. Ischemia persisted in the postoperative period in 8 of 11 placebo patients (73%), but only 5 of 15 esmolol patients (33%) (P < 0.05). Of the 15 esmolol patients, 9 had mean heart rates below the ischemic threshold, and all 9 had no postoperative ischemia. A total of 4 of 11 placebo patients had mean heart rates below the ischemic threshold, and 3 of the 4 had no postoperative ischemia. There were two postoperative cardiac events among patients who had postoperative ischemia (one placebo, one esmolol) and whose mean heart rates exceeded the ischemic threshold. Our data suggest that patient-specific, strict heart rate control aiming for a predefined target based on individual preoperative ischemic threshold was associated with a significant reduction and frequent elimination of postoperative myocardial ischemia among high-risk patients and provide a rationale for a larger trial to examine this strategy's effect on cardiac risk.

IMPLICATIONS

Patients who undergo peripheral vascular surgery often experience transient cardiac complications and/or permanent heart damage just after surgery because of inadequate myocardial blood flow. In this study, we identified patients at high risk of cardiac complications after vascular surgery and showed that if their heart rate was carefully controlled for 48 h after surgery, myocardial ischemia, a common marker of heart injury, was markedly reduced.

N-Acetylaspartate distribution in rat brain striatum during acute brain ischemia

Brain N-acetylaspartate (NAA) can be quantified by in vivo proton magnetic resonance spectroscopy (1H-MRS) and is used in clinical settings as a marker of neuronal density. It is, however, uncertain whether the change in brain NAA content in acute stroke is reliably measured by 1H-MRS and how NAA is distributed within the ischemic area. Rats were exposed to middle cerebral artery occlusion. Preischemic values of [NAA] in striatum were 11 mmol/L by 1H-MRS and 8 mmol/kg by HPLC. The methods showed a comparable reduction during the 8 hours of ischemia. The interstitial level of [NAA] ([NAA]e) was determined by microdialysis using [3H]NAA to assess in vivo recovery. After induction of ischemia, [NAA]e increased linearly from 70 micromol/L to a peak level of 2 mmol/L after 2 to 3 hours before declining to 0.7 mmol/L at 7 hours. For comparison, [NAA]e was measured in striatum during global ischemia, revealing that [NAA]e increased linearly to 4 mmol/L after 3 hours and this level was maintained for the next 4 h. From the change in in vivo recovery of the interstitial space volume marker [14C]mannitol, the relative amount of NAA distributed in the interstitial space was calculated to be 0.2% of the total brain NAA during normal conditions and only 2 to 6% during ischemia. It was concluded that the majority of brain NAA is intracellularly located during ischemia despite large increases of interstitial [NAA]. Thus, MR quantification of NAA during acute ischemia reflects primarily changes in intracellular levels of NAA.

MR-visible brain water content in human acute stroke

Quantification of metabolite concentrations by proton magnetic resonance spectroscopy (1H-MRS) in the human brain using water as an internal standard is based on the assumption that water content does not change significantly in pathologic brain tissue. To test this, we used 1H-MRS to estimate brain water content during the course of cerebral infarction. Measurements were performed serially in the acute, subacute, and chronic phase of infarction. Fourteen patients with acute cerebral infarction were examined as well as 9 healthy controls. To correlate with regional cerebral blood flow (rCBF) SPECT-scanning using 99mTc-HMPAO as flow tracer was performed in the patients. Mean water content (SD) in the infarct area was 37.7 (5.1); 41.8 (4.8); 35.2 (5.4); and 39.3 (5.1) mol x [kg wet weight](-1) at 0-3; 4-7; 8-21; and >180 days after stroke, respectively. Water content increased between Day 0-3 and Day 4-7 (p = 0.034) and decreased from Day 0-3 to Day 8-21 (p = 0.028). Water content at Day 4-7 was significantly higher than in controls (p < or = 0.05). At the same time intervals, mean rCBF (SD) was 76 (23); 94 (31); 106 (35); and 64 (26)%, respectively. There was a significant increase in rCBF from Day 0-3 to Day 4-7 (p = 0.050) and from Day 0-3 to Day 8-21 (p = 0.028). No correlation between rCBF and water content was found. Water content in ischemic brain tissue increased significantly between Day 4-7 after stroke. This should be considered when performing quantitative 1H-MRS using water as an internal standard in stroke patients.

Selected key issues in the development and drafting of public managed behavioral health care carve-out contracts

The development of managed behavioral health care carve-out contracts covering a discrete subset of benefits available for use by persons with mental health and/or substance abuse disorders poses major challenges for public purchasers. This Issue Brief explores several key issues that arise when drafting such agreements. Many of the issues that arise in the drafting of carve-out agreements will require the public purchaser to resolve basic policy questions well before the drafting of requests for proposals or contracts can proceed. Analyses of public sector managed behavioral health care contracts by attorneys at the Center for Health Policy Research suggest that there are four essential areas that must be addressed if mental health and substance abuse services are carved-out (either by the purchaser or by a comprehensive managed health care entity): (1) what population is eligible for enrollment; (2) what services is the contractor expected to furnish; (3) what triggers a duty on the part of the mental health or substance abuse carve-out contractor to provide services; and (4) how are services furnished by the managed behavioral health care contractor integrated with or coordinated with services furnished by a beneficiary's primary health care provider, with pharmaceutical benefits, and with other services that may be available to a beneficiary through a fee-for-service or other mechanism. However a purchaser chooses to resolve these four issues, it is essential that parallel clarifying clauses are also built into the contracts of primary health care providers and other entities providing needed services for persons whose mental health and substance abuse service needs are covered by the carve-out. Underlying all of these issues is the fact that ambiguity, vagueness, or failure to define terms and responsibilities can create unexpected and unwelcome clinical and financial liabilities to purchasers.

An overview of Medicaid managed care litigation

Since the enactment of Medicaid in 1965, states have had the option of offering beneficiaries enrollment in managed care arrangements. With the advent of mandatory managed care reaching millions of beneficiaries (including a growing proportion of disabled recipients), the amount and scope of litigation involving Medicaid managed care plans can be expected to grow. A review of the current litigation regarding Medicaid managed care reveals two basic types of lawsuits: (1) those that challenge the practices of managed care companies under various federal and state laws that safeguard consumer rights, protect health care quality, and prohibit discrimination; and (2) suits that assert claims arising directly under the Medicaid statute and implementing regulations, as well as claims related to Constitutional safeguards that undergird the program. Lawsuits asserting claims arising under Medicaid tend to raise two basic questions: (1) the extent to which enrollment in a Medicaid managed care plan alters existing Medicaid beneficiary rights and state agency duties under federal or state Medicaid law; and (2) the extent to which managed care companies, as agents of the state, act under "color of law" (i.e., undertaking to perform official duties or acting with the imprimatur of state authority). Additionally, states might see an increase in litigation brought by prospective and current contractors who assert that they have been wrongfully denied contracts or improperly penalized for poor performance. These assertions may involve claims that are grounded in federal and state law, the Medicaid statute, and the Constitution. Moreover, in light of the consumer protection elements of the managed care reforms contained in the Balanced Budget Act, future managed care litigation may focus on the manner in which companies carry out states' obligations toward managed care enrollees. Resolution of Medicaid managed care cases involves the application of general principles of administrative and regulatory law. Thus, Medicaid managed care cases have implications for other public purchasers of managed care arrangements, including state mental health and alcohol and substance abuse agencies.

Tuberculosis control in a changing health care system: model contract specifications for managed care organizations

Increasingly, patients with tuberculosis are receiving clinical care in managed care organizations as a result of enrollment in Medicaid or Medicare, or coverage under privately purchased insurance policies or employee benefit plans. This represents a change from the system that has been in place for decades, where the clinical care and public health functions concerning treatment and control of tuberculosis occurred primarily in local health departments. The separation of individual patient care from the public health aspects of tuberculosis control has created challenges for managed care administrators, medical providers, and public health officials. To assist in the integration of the goals of managed care and public health with respect to the prevention and control of tuberculosis, we developed a set of model contract specifications for use by purchasers of managed care and by managed care organizations concerning the management of patients with tuberculosis and other related public health issues. These specifications can assist health officials in continuing their leadership roles by ensuring that managed care contracts address public health needs.

Coverage decision-making in Medicaid managed care: key issues in developing managed care contracts

Coverage provisions are the most complex part of any managed care contract. This is particularly true for Medicaid agencies, because of important differences between Medicaid and insurance. This Issue Brief identifies general issues that should be addressed by States as managed care contracts are developed and drafted, and it specifically explores the challenges faced by public purchasers when drafting managed care coverage provisions.

Negotiating the new health system: purchasing publicly accountable managed care

The transformation to managed care is one of the most important and complex changes ever to take place in the American health system. One key aspect of this transformation is its implications for public health policy and practice. Both public and private buyers purchase managed care; increasingly, public programs that used to act as their own insurers (i.e., Medicare, Medicaid and CHAMPUS) are purchasing large quantities of managed care insurance from private companies. The transformation to managed care is altering the manner in which public health policy makers conceive of and carry out public health activities (particularly activities that involve the provision of personal health services). The degree to which managed care changes public health and in turn is altered by public health will depend in great measure on the extent to which public and private policy makers understand the implications of their choices for various aspects of public health and take steps to address them. Because both publicly and privately managed care arrangements are relatively deregulated, much of the dialogue between public health and managed care purchasers can be expected to take place within the context of the large service agreements that are negotiated between buyers and sellers of managed care products. This is particularly true for Medicaid because of the importance of Medicaid coverage, payment and access policies to public health policy makers, and because of the public nature of the Medicaid contracting process. A nationwide study of Medicaid managed care contracts offers the first detailed analysis of the content and structure of managed care service agreements and the public health issues they raise. Four major findings emerge from a review of the contracts. First, most of the agreements fail to address key issues regarding which Medicaid-covered services and benefits are the contractor's responsibility and which remain the residual responsibility of the state agency. Second, most contracts fail to address the legal and structural issues arising from the relationship between the managed care service system and the public health system, including such key matters as access to care for communicable diseases and contractors' relationship to state public health laboratories. Third, many contracts are silent on health agencies' access to data for surveillance and community health measurement purposes. Finally, many contracts may be developed with only a limited understanding of the key public health-related issues facing the community from which the members will be drawn. The CDC and state and local public health agencies must expand their activities in the area of managed care contract specifications. For several years the CDC has been involved in an ongoing effort to develop quality of care measures to be collected from all companies through the HEDIS process. As important as this effort is, it represents only an attempt to measure what managed care does rather than an a priori effort to shape the underlying policy and organizational structure of managed care itself. Integrating managed care with public health policy will require this type of affirmative effort with both Medicaid agencies as well as other managed care purchasers.

State funding of comprehensive primary medical care service programs for medically underserved populations

OBJECTIVES

This study examined the availability of state funding for comprehensive primary care programs and the need for primary care subsidies for medically underserved communities.

METHODS

A brief questionnaire was used to ask health agencies in all 50 states whether their state funded a program that met our definition of comprehensive primary medical care practice programs. An in-depth written survey instrument was then administered to the states with programs.

RESULTS

Almost half of all states provide some funds for the development and/or operation of comprehensive primary medical care practices. Expenditures in most states were found to be relatively modest in comparison with both federal funding and the total level of unmet need for primary care. States that subsidize primary care practices tend to follow the model established under the federal health centers program.

CONCLUSIONS

The findings suggest the continued viability of the health center model of care, as well as the presence of some state support for such a program. However, in light of limited state resources for the development and operation of comprehensive practices, a continued and significant federal effort is imperative.

State Medicaid and MCO-CBO contracting. The George Washington University studies

The web of contracts between purchasers, plans, and providers will ultimately shape the American healthcare system. Managed care contracts represent a marked departure from common law principles which allowed healthcare providers to decide when and under what circumstances they would enter into a provider/patient relationship. In two studies supported by the Substance Abuse and Mental Health and Services Administration (SAMHSA), contracts for behavioral healthcare services between Medicaid agencies and MCOs, and between MCOs and community-based mental health and substance abuse organizations were examined. Contracts typically cover both mental health and substance abuse treatment services, but state-to-state variation in procedures and specific services covered is the hallmark of behavioral healthcare contracts across the board.

The children's hour: the State Children's Health Insurance Program

The State Children's Health Insurance Program (CHIP) is the product of a series of policy and political compromises and generates numerous structural and policy issues for states. CHIP entitles states to federal financial aid to provide health assistance to targeted children, through Medicaid expansions, new program implementation, or a product of the two. States that elect to operate CHIP programs apart from Medicaid have enormous discretion under the law to determine how they will structure their programs, the services they will cover, the form that benefits will take, and the conditions of participation and consumer protections that will apply. Determining what approach to take, as well as how to respond to the choices posed by the statute, represents a major test of how states address the needs of children and families.

Medicaid managed care and the family planning free-choice exemption: beyond the freedom to choose

Family planning services represent one of the most common managed care services, particularly in the case of Medicaid. In 1986, Congress enacted legislation exempting family planning services from mandatory managed care requirements. The effect of this legislation was to permit beneficiaries enrolled in mandatory managed care plans to continue to obtain family planning benefits from the providers of their choice, regardless of the providers' network status. The purpose of the law was to assure that managed care would not impede individuals' access to benefits. Subsequent experiences surrounding implementation of this provision indicated that the Health Care Financing Administration failed either to define the scope of the exemption or to provide guidance to states regarding the various issues that would have to be resolved in exempting certain primary care services from mandatory managed care. States, in turn, developed working definitions of exempt family planning services that omitted treatment for sexually transmitted diseases and also delegated to their managed care contractors the responsibility to design implementation and payment arrangements. This systematic failure to articulate the scope and functional elements of the exemption consequently led to nonpayment of providers, and ultimately, to denial of care in some cases. Moreover, plans and community providers alike relied on the exemption to justify their failure to come to grips with the requirements and challenges of managed care. We conclude that exempting primary care services from managed care requirements may raise as many questions as it answers, and instead recommend that states, plans, and community providers focus on developing managed care systems that are responsive to patient needs.

Quantification of brain metabolites in amyotrophic lateral sclerosis by localized proton magnetic resonance spectroscopy

We performed proton magnetic resonance spectroscopy (1H-MRS) in patients with motor neuron disease (MND) to determine the absolute in vivo concentrations in the brain of the metabolites N-acetyl aspartate (NAA), choline (Cho), and creatine (Cr/PCr). We examined the spectra acquired from a 20 x 20 x 20-mm3 voxel placed in the motor cortex and in the cerebellum from seven patients with clinically probable or definite amyotrophic lateral sclerosis (ALS) according to the El Escorial criteria, from three patients with suspected ALS (progressive muscular atrophy), and from eight normal control subjects. We estimated the concentrations of the metabolites using the water signal as an internal standard. The concentrations of Cho and Cr/PCr in both brain regions, as well as the concentration of NAA in the cerebellum, were unaltered in the MND patients compared with the controls. Only MND patients with both upper and lower motor neuron signs had a significantly decreased concentration of NAA (9.13 +/- 0.28 mM, mean +/- SEM) in the primary motor cortex when compared with healthy controls (10.03 +/- 0.22 mM). In conclusion, the slightly decreased concentration of NAA in the primary motor cortex from ALS patients may represent a loss of neurons in this region.

High-volume nonionic dimeric contrast medium: first experiences during complex coronary interventions

Interventional cardiology is a rapidly developing field of medicine with annually increasing numbers of coronary interventions. Especially through the development of alternative techniques for coronary angioplasty, new indications have been found and more difficult lesions are tackled. Inevitably, such complex interventions are time-consuming and require high amounts of contrast medium. Newer, mostly nonionic agents have been developed with improved tolerability as well as fewer cardiac and renal side effects due to their nonionic, hydrophilic structure, and their osmolality isotonic to plasma. This study sought to investigate the effects of high-volume nonionic, dimeric contrast medium during coronary interventions with special emphasis on renal and hemodynamic side effects during routine hospital stays. Retrospectively, 25 consecutive patients (age 56 +/- 10 yr) with normal renal and cardiac function receiving > 500 ml of the nonionic dimeric contrast medium iodixanol during complex coronary interventions were analyzed. The analysis was based on serum creatinine levels 1 day before and 2 days after contrast medium administration for the monitoring of renal function. Additionally, heart rate and left ventricular pressures were evaluated before and after left ventricular angiography. Mean serum creatinine rose from 0.9 +/- 0.2 mg/dl to 1.1 +/- 0.2 mg/dl (P < 0.05) after 2 days of coronary intervention. Heart rate, left ventricular systolic pressure, and left ventricular end-diastolic pressure did not change significantly. No major side effects were encountered in the short follow-up period of 2 days. Based on this retrospective analysis, high-volume nonionic, dimeric contrast medium administration in patients without preexisting renal insufficiency is associated with little impairment of renal function, and has only minor hemodynamic and general side effects. Iodixanol 320 mg I/ml is well-tolerated and effective for the use of cardioangiography. Given the limitations of this retrospective analysis, future prospective studies should systematically address the effects of high-volume contrast medium administration in otherwise healthy patients as well as in high-risk patients undergoing coronary interventions.

Medicaid managed care and public health policy

This article provides an overview of managed care concepts and highlights several issues for public health practitioners. Taken from a transcription, this summary is based on a Forum on Public Health and Health Reform held in Atlanta, Georgia, on May 12, 1995, sponsored by the Public Health Practice Program Office, Centers for Disease Control and Prevention. Examples of issues related to managed care for public health practitioners discussed here include: (1) building on managed care plan report cards for large employers so they have an expanded community perspective; (2) developing report cards for Medicaid managed care plans; (3) obtaining patient encounter information from managed care plans for purposes of surveillance and epidemiologic studies; (4) adjusting provider utilization profiles to take into account the differences in the population being served; (5) linking managed care plans with specialized public health providers and community institutions; and (6) consumer surveys related to prevention and public health services.

Civil rights in a changing health care system

Title VI of the 1964 Civil Rights Act prohibits discriminatory conduct by recipients of federal financial assistance. The law has been used in the past to challenge discrimination in health care. The evolution of the health care system from fee-for-service to managed care holds much promise for minority persons, who historically have faced serious, extensively documented barriers to health care access. However, managed care providers, like their fee-for-service counterparts, may perpetuate past discriminatory practices in new ways. Understanding new forms of discrimination is important at this stage of the development of managed care, when program design and policy action can most effectively prevent the occurrence of such practices.

National Asthma Education and Prevention Program working group report on the financing of asthma care

The financing of asthma care is the third topic of the National Asthma Education and Prevention Program Task Force Report on the Cost Effectiveness, Quality of Care, and Financing of Asthma Care. This working group explored the effects of financing on access to services, treatment of asthma, and potential health outcomes. Over the course of a year, the working group collected and analyzed information pertaining to the various types of public and private health care financing mechanisms, including both insurance-based and non-insurance-based issues. The group examined the published literature and gathered information from four public hearings conducted across the nation. The result of this synthesis of information on health care financing and asthma care is a set of 12 recommendations that seek to improve the financing of asthma care.