Risk transfer and accountability in managed care organizations' carve-out contracts.

OBJECTIVE: This study examined characteristics of contracts between managed care organizations (MCOs) and managed behavioral health organizations (MBHOs) in terms of delegation of functions, financial arrangements between the MCO and the MBHO, and the use of performance standards. METHODS: Nationally representative administrative and clinical information about the three largest types of commercial products offered by 434 MCOs in 60 market areas was gathered by telephone survey. These products comprised services provided by health maintenance organizations, preferred provider organizations, and point-of-service plans. Chi square tests were performed between pairings of all three types of products to ascertain differences in the degree to which claims processing, maintenance of provider networks, utilization management, case management, and quality improvement were delegated to MBHOs through specialty contracts among the various types of products. Contractual specifications about capitation arrangements, risk sharing, the use of performance standards, and final utilization review decisions were also compared. RESULTS: For all types of products, almost all the major functions were contracted by the MCO to the MBHO. Although most contracts assigned some risk for the costs of services to the MBHO, the degree of this risk varied by product type. Except in the case of preferred-provider organizations, a large number of performance standards were identified in MCOs' contracts with MBHOs, although financial incentives were rarely tied to such standards. CONCLUSIONS: MCOs that contract with MBHOs place major responsibility, both financial and administrative, on the vendors.

Structural elements of the osteopontin SVVYGLR motif important for the interaction with alpha(4) integrins.

The osteopontin SVVYGLR motif binds the integrins alpha(4)beta(1) and alpha(9)beta(1). We show that alpha(4)beta(7) also interacts with this motif and that an SVVYGLR-OH peptide antagonises the alpha(4)beta(7) MAdCAM interaction. The important elements of this motif required to bind alpha(4)beta(1) and alpha(4)beta(7) were probed using a series of mutated peptides based around SVVYGLR. Leu167 is important for the interaction with alpha(4) integrins, as is the C-terminal carboxylic acid of Arg168 exposed by thrombin cleavage. The importance of the acidic group means that SVVYGLR has structural elements in common with other alpha(4) integrin-binding motifs and suggests why thrombin cleavage activates this motif.

Benefits in behavioral health carve-out plans of Fortune 500 firms.

OBJECTIVE: This study examined the prevalence and nature of behavioral health carve-out contracts among Fortune 500 firms in 1997. METHODS: A survey was conducted of 498 companies that were listed as Fortune 500 firms in 1994 or 1995. A total of 336 firms (68 percent) responded to the survey. Univariate analyses were used to analyze prevalence, types, and amounts of covered services, cost sharing, and benefit limits. A total of 132 firms reported contracting with managed behavioral health organizations; 124 firms answered benefits questions about covered services, cost-sharing levels, and annual and lifetime limits. RESULTS: Most of the plans covered a broad range of services. Cost sharing was typically required, and for inpatient care it was often substantial. Fifteen percent of the firms offered mental health benefits that were below the limits defined in this study as minimal benefit levels, and 34 percent offered substance abuse treatment benefits that fell below minimal levels. The most generous mental health benefits and substance abuse treatment benefits, defined as no limits or a lifetime limit only of $1 million or more, were offered by 31 percent and 20 percent of the firms, respectively. CONCLUSIONS: The carve-out contracts of the Fortune 500 firms in this study typically covered a wide range of services, and the benefits appeared generous relative to those reported for other integrated and carve-out plans. However, these benefits generally did not reach the level of parity with typical medical benefits, nor did they fully protect enrollees from the risk of catastrophic expenditures.

Access to services in the substance abuse treatment system. Variations by facility characteristics.

In view of the importance of type and intensity of services during substance abuse treatment, this chapter looks at treatment and support services that substance abuse clients have access to during treatment. Trends in services over recent years are described. Services available to clients in the current treatment system are reviewed. Several facility characteristics affecting access to services are examined. Different ways of defining access to services are discussed. Findings from the Alcohol and Drug Services Study are used to illustrate service patterns in the national substance abuse treatment system. Variations in service patterns by facility characteristics such as type of care, treatment setting, ownership, percent of facility dependence on public revenue, and level of affiliation are analyzed. The implication is that clients who enter into treatment at different types of facilities are likely to have access to certain types of services.

Financing of substance abuse treatment services.

The financing of treatment for substance abuse problems has differed from the rest of financing of health care in part because of the dominant role of the public sector as the payer of services. Nonetheless, the rise of managed care has affected substance abuse treatment services as well as the rest of the health care system. Alternative payment mechanisms are one important component of some managed care approaches. Behavioral health carve-outs are another managed care development that has affected substance abuse services. In this chapter, salient features of financing for substance abuse treatment are reviewed within the conceptual framework of payers (purchasers and intermediaries), providers, and consumers. Existing literature on substance abuse treatment financing is summarized, while recognizing that much remains to be researched.

Organizational and financial issues in the delivery of substance abuse treatment services.

Examination of organizational and financial characteristics of the specialty substance abuse treatment system allows an understanding of how to meet the needs of clients in the system. Further, this assessment may afford insights into how the specialty sector may adapt in the changing environment of managed care. Data from Phase I of the Alcohol and Drug Services Study (ADSS) describe the specialty substance abuse treatment system in terms of type of care, setting, level of affiliation, licensure/accreditation, ownership, revenue sources, client referral sources, client's primary substance of abuse, and managed care. Although the system is largely outpatient and remains substantially two tiered in terms of public/private funding mix, it varies along a number of organizational and financial dimensions which have implications for system structure and facility viability in the changing environment of substance abuse treatment service delivery.

Analysis of the alpha4beta1 integrin-osteopontin interaction.

The integrin alpha4beta1 is involved in mediating exfiltration of leukocytes from the vasculature. It interacts with a number of proteins up-regulated during the inflammatory response including VCAM-1 and the CS-1 alternatively spliced region of fibronectin. In addition it binds the multifunctional protein osteopontin (OPN), which can act as both a cytokine and an extracellular matrix molecule. Here we map the region of human OPN that supports cell adhesion via alpha4beta1 using GST fusion proteins. We show that alpha4beta1 expressed in J6 cells interacts with intact OPN when the integrin is in a high activation state, and by deletion mapping that the alpha4beta1 binding region in OPN lies between amino acid residues 125 and 168 (aa125-168). This region contains the central RGD motif of OPN, which also interacts with integrins alphavbeta3, alphavbeta5, alphavbeta1, alpha8beta1, and alpha5beta1. Mutating the RGD motif to RAD had no effect on the interaction with alpha4beta1. To define the binding site the region incorporating aa125-168 was divided into 5 overlapping peptides expressed as GST fusion proteins. Two peptides supported adhesion via alpha4beta1, aa132-146, and aa153-168; of these only a synthetic peptide, SVVYGLR (aa162-168), derived from aa153-168 was able to inhibit alpha4beta1 binding to CS-1. These data identify the motif SVVYGLR as a novel peptide inhibitor of alpha4beta1, and the primary alpha4beta1 binding site within OPN.

Why carve out? Determinants of behavioral health contracting choice among large U.S. employers.

Many U.S. employers have carved substance abuse and mental health services out of their medical plans, changing the way millions of people access care. Employers that take this approach contract directly with specialized vendors, bypassing their general health plans. Since carving out may alter access and treatment, there is a need to understand why employers take this approach. This article reviews various hypotheses about why purchasers carve out and tests them using data from a survey of America's largest employers, the Fortune 500 firms. Size is the strongest predictor of an employer's decision to carve out behavioral health once other characteristics are controlled for. Employers that report they value coordination are less likely to carve out, while those that value special expertise are more likely to carve out. Employers are less likely to carve out enrollees in health maintenance organizations (HMOs) than those in other types of plans.

A regulated interaction between alpha5beta1 integrin and osteopontin.

The extracellular matrix protein osteopontin (OPN) interacts with a number of integrins, namely alphavbeta1, alphavbeta3, alphavbeta5, alpha9beta1, alpha8beta1, and alpha4beta1. We have investigated the interaction of alpha5beta1 integrin with OPN using K562 cells, which only express alpha5beta1. alpha5beta1 is in a low activation state in this cell line, but can be stimulated to a higher activation state by the phorbol ester TPA. Treating K562 wild-type cells (K562-WT) with TPA stimulated an interaction between alpha5beta1 and OPN. No interaction was seen in the absence of TPA. alpha5beta1 selectively interacted with a GST fusion protein of the N-terminal fragment of OPN (aa17-168), which is generated in vivo by thrombin cleavage of OPN. Expression of the alpha4 integrin in K562 cells (K562-alpha4beta1) stimulated alpha5beta1-dependent binding to aa17-168 in the absence of TPA, suggesting that alpha4beta1 activates alpha5beta1 in K562 cells. Adhesion via alpha5beta1 is mediated by the Arg-Gly-Asp (RGD) motif of OPN, as mutating this sequence to Arg-Ala-Asp (RAD) blocked binding of both cell types. These data demonstrate that thrombin cleavage regulates the adhesive properties of OPN and that alpha5beta1 integrin can interact with thrombin-cleaved osteopontin when in a high activation state.

Use of performance standards in behavioral health carve-out contracts among Fortune 500 firms.

OBJECTIVE: To determine the prevalence and nature of performance standards in specialty managed behavioral healthcare contracts among Fortune 500 companies. STUDY DESIGN: This was a cross-sectional survey of all companies listed on the Fortune 500 during 1994, 1995, or both. METHODS: From April 1997 to May 1998 we conducted a mailed survey with phone follow-up. Of the 68% of firms that responded, over one third reported carve-out contracts. The survey focused on whether companies had behavioral health carve-out contracts with specialty vendors and characteristics of these contracts, including the use of performance standards. RESULTS: More than three quarters of the Fortune 500 companies reporting specialty behavioral healthcare contracts used at least one performance standard. Most common were administrative standards (70.2%) and customer service standards (69.4%). About half of the companies used quality standards, whereas only a third used provider-related standards. Most (58.8%) companies using performance standards also specified financial consequences. Larger Fortune 500 firms were significantly more likely to use performance standards. Risk contracts and contracts that included all covered employees were also more likely to include some categories of standards. CONCLUSIONS: Administrative and customer service standards may be most common because companies find it easier to specify those standards, especially compared with clinical quality measures. To the extent that employers want to obtain the most value from their behavioral healthcare purchasing, we expect that more will begin to adopt quality standards in their contracts, especially as performance measures become more refined. Reliance on accreditation, however, is an alternative approach for employers.

Tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta down-regulate intercellular adhesion molecule (ICAM)-2 expression on the endothelium.

Leukocyte recruitment is a crucial step in inflammation. Inflammatory stimuli upregulate the expression of some endothelial adhesion molecules, such as E-selectin or ICAM-1, but not of others such as ICAM-2. ICAM-2, a constitutively expressed endothelial ligand for beta2 integrins LFA-1 and Mac-1, is involved in leukocyte adhesion to resting endothelium and in transmigration in vitro, however its role in inflammation is unclear. We have studied the effect of TNF-alpha and IL-1beta on ICAM-2 expression on human umbilical vein endothelial cells (HUVECs). Prolonged treatment (24 h) of HUVECs with TNF-alpha (10 ng/ml) or IL-1beta (34 ng/ml) reduced ICAM-2 surface expression to 50% of control, while interferon (IFN)-gamma had no effect. The loss in ICAM-2 surface expression correlated with a reduction of ICAM-2 mRNA to approximately 40% of control after 24 h of cytokine treatment. The activity of an ICAM-2 promoter reporter plasmid transfected into HUVECs was down-regulated by TNF-alpha and IL-1beta to similar values. Thus inflammatory cytokines inhibit ICAM-2 transcription, despite the absence of known cytokine-responsive elements in the promoter. Immunocytochemistry on HUVEC monolayers showed that ICAM-2 expression, mainly at the cell junctions in resting cells, was markedly decreased by cytokine treatment. This data suggest that ICAM-2 expression on the endothelium may be regulated during inflammation.

Make or buy: HMOs' contracting arrangements for mental health care.

Many health maintenance organizations (HMOs) are contracting with external vendors for mental health care, rather than maintaining an internal mental health department. We develop a framework for analyzing HMOs' contracting choices, rooted in transaction cost economics. Applying this framework, external contracting seems most likely to appeal to smaller, newer HMOs and those located in areas with multiple vendors. Pressure from value-oriented buyers may make it harder for HMOs to provide mental health internally, without costly reforms to their product. HMO contracting arrangements deserve further study, given their implications for cost and the quality of care.

Private sector coverage of people with dual diagnoses.

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

A rapid activation assay for human eosinophils based on adhesion to immobilized ICAM-1, VCAM-1 and IgG.

Interleukin 5 (IL-5) is a T-cell derived cytokine that induces eosinophil growth and differentiation in both mouse and human bone marrow cultures. Elevated levels of IL-5 as well as eosinophils have been detected in the sputum and Bronchoalveolar lavage (BAL) fluids of asthmatics. Since the recruitment of inflammatory cells to tissues requires the participation of adhesion molecules, we have developed a rapid and sensitive assay to examine the effect of IL-5 and other activation stimuli on eosinophil adhesion to recombinant intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1). Human recombinant IL-5, granulocyte-macrophage colony stimulating factor (GM-CSF), interleukin 3 (IL-3), tumour necrosis factor alpha (TNF-alpha), RANTES, MCP-3, C5a, PAF, fMLP, PMA and ConA all induced adhesion of purified eosinophils obtained from normal donors to ICAM-1 and VCAM-1 in a dose and time dependent manner. Adhesion was rapid, within 15 minutes of culture at 37 degrees C, and plateaued within 30 minutes. Activated eosinophils also adhered rapidly to immobilized IgG via the type II Fc gamma receptor (CD32). Analysis of the effect of IL-5 on surface molecule expression by FACS analysis revealed increased expression of CD11b molecules and decreased expression of L-selectin, but no change in the expression of CD11a, CD18, CD29, CD49d and CD32. We also show that Mac-i plays an important role in the regulation of eosinophil activation, since antibodies to CD11b can block IL-5 induced adhesion to IgG and IL-5 induced degranulation.

Inpatient and outpatient psychiatric services: substitutes or complements?

Patients at risk for psychiatric hospitalization make only limited use of outpatient services, although clinical research has demonstrated that outpatient treatments and home care can be as effective as inpatient psychiatric treatment in treating certain mental health problems. The substitution of ambulatory services for inpatient care has in part been limited because insurers have restricted outpatient mental health benefits to control utilization. The authors critically review evidence from the economic and clinical literatures to determine the extent to which outpatient psychiatric treatment substitutes or complements inpatient treatment. To encourage clinically effective substitution of outpatient for inpatient services, further research is needed to identify the patient populations for whom substitution is possible and the treatment and environmental conditions in which it is most likely to be successful.

The reporting of stigmatizing health conditions: a comparison of proxy and self-reporting.

Previous studies have found that self-respondents tend to report a greater number of health problems than do household proxies. It has not been clear, however, if such results indicate reporting bias or reflect underlying health differences in the self-respondent and household proxy populations. Verification data from a survey of medical providers were examined in conjunction with the results of a national household survey. Our analysis indicates that the use of proxies does not increase misreporting. Overall reporting error between self-respondents and proxy-respondents is comparable on reports of mental illness. When physical stigmatizing conditions are examined, the use of proxies actually appears to be preferable to interviewing respondents directly.

The demand for ambulatory mental health services from specialty providers.

A two-part model is used to examine the demand for ambulatory mental health services in the specialty sector. In the first equation, the probability of having a mental health visit is estimated. In the second part of the model, variations in levels of use expressed in terms of visits and expenditures are examined in turn, with each of these equations conditional on positive utilization of mental health services. In the second part of the model, users are additionally grouped into those with and without out-of-pocket payment for services. This specification accounts for special characteristics regarding the utilization of ambulatory mental health services: (1) a large part of the population does not use these services; (2) of those who use services, the distribution of use is highly skewed; and (3) a large number of users have zero out-of-pocket expenditures. Cost-sharing does indeed matter in the demand for ambulatory mental health services from specialty providers; however, the decision to use mental health services is affected by the level of cost-sharing to a lesser degree than is the decision regarding the level of use of services. The results also show that price is only one of several important factors in determining the demand for services. The lack of significance of family income and of being female is notable. Evidence is presented for the existence of bandwagon effects. The importance of Medicaid in the probability of use equations is noted.

Specialty and general ambulatory mental health services. Comparison of utilization and expenditures.

A substantial amount of ambulatory mental health services are received outside of the specialty mental health sector; however, precise estimates are lacking. To determine national estimates of utilization and expenditures for total ambulatory mental health services, as well as separate estimates for the specialty mental health and general medical sectors, patterns of use were examined by standard demographic characteristics. Almost 5% of the US population in 1977 had at least one ambulatory visit in conjunction with a mental problem. Three fifths of users received their care in the general medical sector; however, two thirds of all mental health visits occurred in the specialty mental health sector. This study indicates that there are significant differences between the two sectors with respect to utilization and expenditure patterns.

Antitumour imidazotetrazines--VIII. Uptake and decomposition of a novel antitumour agent mitozolomide (CCRG 81010; M and B 39565; NSC 353451) in TLX5 mouse lymphoma in vitro.

The uptake and incorporation of 8-carbamoyl-3-(2-chloroethyl)(6-14C-imidazo)[5,1-d]-1,2,3,5-tetrazin+ ++-4-(3H)- one (Mitozolomide) into TLX5 mouse lymphoma cells has been studied in vitro. Uptake was rapid, reaching a cell/medium distribution of approximately unity in 1 min at 37 degrees and 10 min at 4 degrees, directly proportional to drug concentration and was unaffected by metabolic inhibitors. These results are consistent with a simple diffusion mechanism. No difference in uptake was observed between drug sensitive and resistant TLX5 lymphoma cells. Cellular radioactivity was found to be progressively accumulated into acid-insoluble material. Acid hydrolysis of this precipitate followed by hplc analysis of the DNA and RNA bases showed that the radioactivity was associated solely with adenine and guanine bases. Mitozolomide was unstable in tissue culture medium and over a 24 hr period about 80% of the drug was converted into 5-aminoimidazole-4-carboxamide (AIC). Non-radioactive AIC suppressed the incorporation of radioactivity into nucleic acids, but had no effects on the initial rate of uptake of mitozolomide into the cell. These results suggest that the radioactivity in nucleic acids arises as a result of salvage of AIC, formed by intracellular decomposition of mitozolomide.