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News and Notes   |    
Psychiatric Services 1999; doi:
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A study by a health care consulting firm has found than as of mid-1998 all but four states had implemented some form of managed behavioral health care in their public-sector treatment programs. Ten states reported that, except for services for specific populations, they no longer had mental health and substance abuse services operating under a fee-for-service system.

The Lewin Group of Fairfax, Virginia, collected the data for the Substance Abuse and Mental Health Services Administration Managed Care Tracking System between January and July 1998. The tracking system serves as a central point for collecting and analyzing information on the impact of managed care on Medicaid behavioral health services and public mental health and substance abuse treatment systems.

A total of 97 managed care programs operating in 47 states included some form of mental health or substance abuse services or both, the study found. Medicaid was the primary vehicle by which states created and funded managed behavioral health care programs. Thirty-six states operated 46 such programs under Medicaid waivers, which allow states to bypass certain federal requirements in the interest of developing community-based treatment alternatives to hospital or nursing home services, improving access to care, or testing new treatment approaches. Approximately two-thirds of the 46 programs provided both mental health and substance abuse services, while a fourth covered mental health services only.

In addition, the study found that 26 states operated 32 managed behavioral health care programs not connected with Medicaid. Ten of the programs offered mental health treatment, six offered substance abuse treatment, and ten provided both types of services.

Predictions that private managed care organizations would take over responsibility for operating public-sector managed behavioral health care programs, just as they did in the general health care sector, so far have not been borne out, the study found. Twenty-six states used public-sector agencies or public-private partnerships to manage their programs, while 20 states contracted with private-sector organizations. However, in ten of the 20 states, the private organizations performed only administrative services in exchange for a fee and did not assume any financial risk.

The study identified several combinations of public-private partnerships used by the states. Some states had contracts with counties, other local government entities, or community providers. In other states a state agency functioned as the managed care entity. In a few states partnerships were formed between community providers or government agencies and behavioral health managed care organizations.

States were more likely to use integrated and stand-alone models for their managed care programs than carve-out models. A total of 46 integrated programs—physical health plans that include a mental health and substance abuse component—were operating in 35 states at the time of the study. However, this model was generally used for services designed for a general population rather than one needing specialized services.

Forty-five stand-alone programs were operating in 33 states, 21 for mental health, eight for substance abuse, and 16 for behavioral health. These programs operated independent of any other program.

Only five states operated full carve-out programs, in which mental health and substance abuse services were completely separated from physical health care programs. Three states operated partial carve-out programs, in which some mental health and substance abuses services were integrated into the general health care program but expanded services were provided in a separate managed care program.

Of the 83 managed care programs that provided information to the Lewin Group on services, more than three-fourths covered inpatient and outpatient mental health services. Half covered mental health rehabilitation services, a third detoxification services, and a fourth mental health and substance abuse residential services.

Eighty-nine programs reported information about financing. Seventy-eight percent received some Medicaid funding, and 36 percent of these programs were funded exclusively by Medicaid dollars. General revenues were the next largest source of funding, at 44 percent, followed by block grants at 18 percent, county funds at 12 percent, state department of mental health allocations at 6 percent, and state department of alcohol and drug abuse allocations at 3 percent.

For more information about the study, contact the Lewin Group at 703-218-5607.

Supreme Court Will Hear Georgia Case on Community Care

The U.S. Supreme Court has agreed to hear a case from Georgia that is expected to clarify whether the Americans With Disabilities Act (ADA) requires states to treat psychiatric patients in the community rather than in a psychiatric hospital.

A federal judge, followed by a U.S. appeals court, ruled that the state violated the antidiscrimination provision of the ADA by confining two patients in the segregated environment of a psychiatric hospital rather than placing them in a community treatment program. The district court said that the denial of community placements could not be justified by the state's purported lack of funds.

Georgia's appeal to the Supreme Court is supported by 22 other states. A decision in the case, Olmstead et al. v. L.C. and E.W., is due by the end of June.

The diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD) remain controversial despite the progress made in understanding and treating it, a national panel of experts acknowledged in a recent consensus statement.

The consensus statement was developed at a National Institutes of Health Consensus Development Conference held last November. David J. Kupfer, M.D., professor and chair of the department of psychiatry at the University of Pittsburgh, served as chair of the 13-member consensus panel, which heard from numerous other experts.

ADHD is estimated to affect 3 to 5 percent of school-age children and is the most commonly diagnosed behavioral disorder of childhood. Core symptoms include developmentally inappropriate levels of attention and concentration and of activity, distractibility, and impulsivity. Children with ADHD usually have pronounced difficulties and impairment at home, at school, and with peers, and also experience long-term adverse effects on later academic, vocational, social-emotional, and psychiatric outcomes.

ADHD can be diagnosed reliably using well-tested diagnostic interview methods, the consensus statement said. However, no independent, valid test for ADHD exists, and there are no data to indicate that it is due to a brain malfunction. Evidence supporting the validity of ADHD includes its predictable course over time, cross-national studies revealing similar risk factors, familial aggregation of ADHD (which may be genetic or environmental), and heritability. The consensus panel called for further efforts to validate the disorder, including careful description of the cases, use of specific diagnostic criteria, repeated follow-up studies, and family studies.

A wide variety of treatments have been used for ADHD, but medications and psychosocial interventions have been the major focus of research. Short-term trials have supported the efficacy of the stimulants methylphenidate, dextroamphetamine, and pemoline for children with ADHD, the consensus statement said. However, despite the beneficial effects of stimulants on ADHD's core symptoms and associated aggressiveness, little improvement in academic achievement or social skills has been found.

Psychosocial treatment of children with ADHD has included behavioral strategies such as contingency management, exemplified by point or token reward systems or timeout, typically conducted in the classroom; training for parents in child management skills; clinical behavior therapy in which parents, teachers, or both are taught to use contingency management procedures; and cognitive-behavioral treatment, which includes self-monitoring, verbal self-instruction, and self-reinforcement. All except cognitive-behavioral management have produced beneficial effects, the consensus statement said.

Little information exists on the long-term effects of psychostimulants, the consensus statement reported, but there is no conclusive evidence that careful therapeutic use is harmful.

Citing barriers to identification and treatment, the consensus statement called for more consistent diagnostic procedures and practice guidelines for ADHD and better communication between diagnosticians and those who implement and monitor treatment in schools. Ideally, primary care practitioners with adequate time for consultation with school teams should be able to make an appropriate assessment and diagnosis, but they should also be able to refer to mental health and other specialists when necessary.

The cost and lack of insurance coverage for diagnosis and treatment of ADHD also pose major barriers to appropriate care, the consensus statement said. Mental health benefits are carved out of many family health insurance policies, limiting access to treatment other than medication. The statement emphasized the need for parity coverage of mental health conditions.

The consensus statement can be found on the Web at http://odp.od.nih. gov/consensus.

Unemployment among persons with severe disabilities hovers around 70 percent, and lack of access to health insurance is a primary reason, the Presidential Task Force on Employment of Adults With Disabilities declared in its first report to President Clinton issued last November. Until the barrier to health care is eliminated, people with disabilities will continue to be forced into dependency and poverty, the task force said.

Established by executive order of President Clinton in March 1998, the task force is charged with creating a coordinated and aggressive national policy to bring adults with disabilities into gainful employment at a rate as close as possible to that of the general adult population. The Secretary of Labor, Alexis Herman, serves as chair of the task force. Vice-chair is Tony Coelho, chairman of the President's Committee on Employment of People With Disabilities. Members include most cabinet officers and administrators of major government agencies.

In addressing the issue of health care, the task force report said that people with disabilities too often cannot obtain health insurance that provides the comprehensive health care needed to live independently and to participate in the workforce. Many disabled people and their families are forced to impoverish themselves to receive critical health care coverage under Medicaid. Others gain access to Medicaid and Medicare through cash benefit programs such as Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI). However, participation in the SSI and SSDI programs makes it impossible for disabled people to return to work without risking the loss of health care.

The task force was especially critical of the low level of income the Social Security Administration allows disabled SSI and SSDI beneficiaries to earn from substantial gainful activity (SGA)—currently $500 a month—without reducing or eliminating their benefits. It urged President Clinton to explore fiscally responsible policies for SGA regulation and to work with Congress to pass affordable legislation that helps people with disabilities maintain their health care coverage and return to work.

The task force pointed out that as part of last year's Balanced Budget Act, states now have the option of allowing people with disabilities who return to work to purchase Medicaid coverage as their earnings increase. While the task force considered this an important option, it emphasized that broader reforms are needed.

The task force expressed optimism that developments in two other areas—technology and education—will provide new opportunities for persons with disabilities. It said that technology is removing the physical and communication barriers that historically have isolated and segregated persons with disabilities and is creating opportunities for telecommuting and entrepreneurial initiatives. The task force said the federal government should be a model in providing state-of-the-art technology for its workers and technological and work-site accommodations for employees with disabilities.

The task force noted recent changes in the Individuals With Disabilities Education Act that mandate a more challenging curriculum and high expectations for every child, increased involvement of and reporting to parents on their children's progress, and expanded and improved teacher training. But it said that more effort is needed to keep students with disabilities from dropping out of school and to prepare them for future employment.

The task force report, entitled Recharting the Course, is accessible on the Web at http://dol.gov/dol/_sec/ public/programs/ptfead/rechart. More information is available from the Presidential Task Force on Employment of Adults With Disabilities, 200 Constitution Avenue, N.W., Room S2312, Washington, D.C. 20210; phone, 202-219-6081 (voice), -0012 (TTY); fax -6523.

Use of illicit drugs by teenagers decreased in almost every drug category in 1998, with the biggest decreases generally occurring among tenth-graders, according to the 24th annual Monitoring the Future Survey released in December by the Department of Health and Human Services. The 1998 study surveyed 49,866 students from a representative sample of 422 public and private schools nationwide.

The survey, which focuses on drug use among eighth-, tenth-, and 12th-graders, found that the proportion of tenth-graders who reported any use of an illicit drug during their lifetime dropped from 47.3 percent in 1997 to 44.9 percent in 1998. Among eighth-graders, lifetime use dropped from 29.4 to 29 percent, and among 12th graders, from 54.3 to 54.1 percent.

Lifetime use of marijuana, the drug most widely used by teenagers, also declined among the three groups. Again, the biggest drop occurred among eighth-graders. In 1998 39.6 percent reported ever using marijuana compared with 42.3 percent in 1997. Marijuana use among 12th-graders dropped from 49.6 to 49.1 percent, and among eight-graders, from 22.6 to 22.2 percent.

Daily use of cigarettes also declined. Among 12th graders, 22.4 percent reported smoking daily in 1998, compared with 24.6 percent in 1997. Daily use among tenth-graders dropped from 18 to 15.8 percent, and among eighth-graders from 9 to 8.8 percent.

The 1998 survey found some encouraging trends in attitudes toward and perceptions of drug abuse. The percentage of eighth-graders reporting great risk in trying marijuana once or twice increased, as did the percentage who perceived great risk in occasional use. More eighth-graders also perceived harm in trying one or two drinks, as did more tenth-graders. The percentage of 12th-graders seeing great risk in trying amphetamines once or twice also increased.

Among eighth- and tenth-graders, the perceived availability of several drugs decreased, including marijuana, LSD, heroin and other opiates, amphetamines, barbiturates, tranquilizers, alcohol, and cigarettes.

The Monitoring the Future Study is conducted annually by the University of Michigan's Institute for Social Research and funded by the National Institute on Drug Abuse. A report is available on the Web at http://www. isr.umich.edu/src/mtf/index.html. For more information, contact the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.




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