Care coordination and physical and behavioral service integration in managed care contracts: analysis and sample purchasing specifications.

This double Issue Brief on the issue of managed care contracts and care coordination has been prepared for the Substance Abuse and Mental Health Services Administration as part of a series that examines legal issues in managed care for persons with mental illness and addiction disorders. This Issue Brief is presented in two parts. Part 1 presents an analysis, based on managed care contract data bases developed by CHSRP, of the extent to which public and private group purchasers maintain agreements that specify care coordination as part of the standard of care for persons with co-occurring physical and/or behavioral illnesses and conditions. Part 2 sets forth sample purchasing specifications that are designed to establish care coordination as part of the standard of care.

EMTALA: reaching beyond the emergency room to expand hospital liability.

The Office of the Inspector General and private plaintiffs are vigorously pursuing EMTALA violations. These efforts are particularly troubling to hospitals, who face difficult statutory interpretation and application questions, especially in light of managed care reimbursement requirements. Two recent cases, one of them from the United States Supreme Court, expand hospital liability under EMTALA. This Article reviews current EMTALA standards and regulations, and analyzes how the recent decisions, in the absence of congressional action, are likely to impose substantial burdens upon hospitals.

Partial integration raises antitrust concerns.

Recently, providers have begun to explore a new model of integrated delivery system, the partially integrated IDS. Typically, a partially integrated IDS is a joint venture, owned by a core group of providers that maintains complete financial and operational independence outside the joint venture. The IDS contracts with other providers to furnish services that the part-owners do not furnish. A partially integrated IDS raises antitrust concerns because the participating providers may be seen as competitors banding together to set prices jointly for healthcare services. Therefore, to minimize their antitrust exposure, providers that are considering this model should be careful to structure the IDS in accordance with the relevant Federal antitrust laws (i.e., Section 1 of the Sherman Act), taking into account the Federal antitrust agencies' various guidelines and enforcement policies.

Group practices say growth good but tough.

McManis Associates, a health care consulting firm, in conjunction with MGMA, sponsored the fourth annual roundtable for executives from leading medical groups across the country. This event is structured to capture key insights related to the success of medical group, with a special focus on medical group growth strategies. This article briefly profiles the roundtable participants and their organizations, summarizes the highlights of the discussion that took place and synthesizes the information into lessons learned that are applicable to other medical groups.