Full Text AA-96-001
NIH GUIDE, Volume 25, Number 1, January 26, 1996
RFA:  AA-96-001
P.T. 34

  Health Services Delivery 
  Health Care Economics 

National Institute On Alcohol Abuse And Alcoholism
Letter of Intent Receipt Date:  March 15, 1996
Application Receipt Date:  April 11, 1996
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) seeks
research applications that are aimed at increasing the knowledge base
on the impact of managed care on the delivery of alcohol treatment
services.  This Request for Applications (RFA) invites research
applications that evaluate the impact of the full spectrum of managed
care approaches on the availability, accessibility, quality,
effectiveness, outcomes, and costs of alcohol treatment services.
The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of Healthy People 2000, a
PHS-led national activity for setting priority areas.  This RFA,
Managed Care and Alcohol Treatment Services, is related to the
priority areas of alcohol abuse reduction and alcoholism treatment.
Potential applicants may obtain a copy of Healthy People 2000 (Full
Report:  Stock No. 017-001-00474-0, or Summary Report:  Stock No.
017-001-00473-1) through the Superintendent of Documents, Government
Printing Office, Washington, DC 20402-9325 (Telephone:
Applications may be submitted by domestic and foreign, for-profit and
non-profit, public and private organizations, such as universities,
colleges, hospitals, laboratories, units of State and local
governments, and eligible agencies of the Federal government.
Racial/ethnic minority individuals, women, and persons with
disabilities are encouraged to apply as Principal Investigators.
Foreign institutions are not eligible for First Independent Research
Support and Transition (FIRST) Awards (R29).
Research support may be obtained through applications for research
project grant (R01) or First Independent Research Support and
Transition (FIRST) Award (R29).  Applicants may also submit
Investigator-Initiated Interactive Research Project Grants under this
RFA.  Interactive Research Project Grants require the coordinated
submission of related research project grant (R01) applications and,
to a limited extent, FIRST (R29) Award applications from
investigators who wish to collaborate on research, but do not require
extensive shared physical resources.  Program Project Grant
applications (P01) will not be accepted under this RFA.
Potential applicants may obtain copies of the FIRST (R29) program
announcement AND IRPG program announcement from the National
Clearinghouse for Alcohol and Drug Information, P.O. Box 2345,
Rockville, Maryland, 20852, telephone: 301-468-2600 or 1-800-
729-6686.  Further information on grant mechanisms and areas of
research interest may be obtained from the program staff listed under
It is estimated that up to $3 million will be available for
approximately 12 grant awards under this RFA in FY 1996.  This level
of support is dependent on the receipt of a sufficient number of
applications of high scientific merit.  The NIAAA estimates that the
average grant size will be approximately $250,000 in total costs,
i.e. direct plus indirect costs, for the first year.  Outyear budgets
should conform to NIH cost containment policies.  Although the
financial plans of NIAAA provide support of this program, the award
of grants pursuant to this RFA is contingent upon the availability of
funds for this purpose.
The system of delivering and financing alcohol treatment services in
the United States is undergoing rapid and substantial change.  This
is due, in large part, to the development of managed health care
systems designed to provide more efficient and cost-effective health
care.  Under managed care, alcohol treatment services are frequently
combined into the broader area of managed behavioral health care,
which includes mental health, alcohol, and drug treatment services.
Currently, managed care is the dominant system for the provision of
privately insured mental health and alcohol and other drug abuse
services -- including an estimated 108 million Americans, or 58
percent of all persons with private health insurance (Oss, 1995).
Publicly funded health insurance programs, such as Medicare and
Medicaid, represent the next major area of growth for managed care.
A number of States, such as Massachusetts and Ohio, have received
waivers from the U.S. Health Care Financing Administration (HCFA),
allowing them to develop managed care programs under Medicaid (Freund
and Hurley, 1995). Another recent trend in the provision of
behavioral health care services is the development of "carve out"
plans, where one vendor manages the utilization of all mental health
and substance abuse benefits (Garnick, 1994).  There is a need to
understand better the nature of managed behavioral health care
arrangements and the impact of these arrangements on access,
utilization, cost, quality, and effectiveness of alcohol treatment.
For the purposes of this RFA, managed care is broadly defined as the
use of one or more of the following mechanisms to manage the delivery
of alcohol treatment services:  (l) utilization review, including the
use of clinical guidelines, protocols and case management techniques;
(2) selective contracting with a network of providers who provide
services in accordances within an agreed- upon system of management
controls; and (3) provider payment mechanisms which encourage cost
containment and may involve some degree of financial risk sharing
(e.g., capitation arrangements, discounted payment schedules).
Currently in the United States, one or more of these managed care
mechanisms are used in the four major types of health care plans:
(1) managed indemnity; (2) health maintenance organizations (HMOs);
(3) preferred provider organizations (PPOs); and (4) point of service
plans (POS).
Key characteristics of managed care programs include a broad range of
organizational and financing features, including the following:
(l) benefit plan characteristics (e.g., types of patient populations,
number and type of allowed services, use of copayments and
(2) use of integrated and carve out management systems;
(3) wide variability in the types and mix of alcohol treatment
services provided;
(4) systems of provider recruitment, selection, and monitoring;
(5) systems of organizational management, case management and quality
assurance, including organizational and clinical decision-making
models, use of clinical guidelines and protocols, provider
credentialing requirements, staffing characteristics, (e.g., staffing
mix, team models), use of performance tracking systems (e.g., report
cards, provider and consumer satisfaction surveys); and
(6) financing mechanisms that incorporate incentives to limit
quantity and cost of care, including risk-sharing arrangements,
deductibles, copayments, capitation, etc.
Available research has focused on the effects of managed care on the
utilization and cost of services.  Case studies of private sector
managed behavioral health care indicate initial year reductions of 30
percent or greater in cost, slightly increased access to care, and
minimal change in consumer satisfaction (Goldman, 1993, Frank,
McGuire and Newhouse, 1995).  The decline in costs of substance abuse
services has been attributed primarily to a reduction in inpatient
service related costs (Callahan, 1994; Mechanic et al., 1995, Larson
et al., 1993).
Current Knowledge Gaps
Despite the rapid adoption of managed behavioral health care
arrangements in the public and private sectors, there has been
relatively little research on the impact of these approaches on the
delivery of alcohol treatment services.  There are a number of areas
where more research is needed.  First, more needs to be known about
the specific organizational and financing characteristics of managed
care programs, how they interrelate, and how they affect service
delivery. Managed care is very heterogeneous and past research has
not always been clear on the specific form of managed care being
evaluated.  Basic descriptive data is needed on the key dimensions of
managed care arrangements (e.g., benefit structure, utilization
review approaches, provider selection, risk sharing arrangements with
providers) and how these forms of managed care are combined and
implemented in the public and private sectors.  Second, more
knowledge is needed about the impact of specific forms of managed
behavioral health care arrangements on access to care and the quality
and outcomes of care.  To date, the major focus of studies of managed
care has been on how managed care arrangements influence utilization
and cost.  A related knowledge gap is how to measure the of quality
of care and clinical outcomes in the context of managed behavioral
health (e.g., performance indicators and report cards).  Third, more
needs to be known about the impact of managed care on clinical
decision making.  Most managed care arrangements include the use of
standardized decision rules for accessing care, for placing patients
in a particular type or intensity of treatment, and for delivering
various treatment modalities, yet the effect of these decision rules
on access, quality and outcomes of care is unknown.  Finally, there
is a need to understand better the impact of managed care programs on
populations of persons who are severely and chronically impaired, who
have low incomes, or who have co-occurring mental health and
substance abuse disorders.
Areas of Research Interest
The primary objective of this RFA is to support studies that will
increase understanding of the impact of managed care systems on
access, utilization, cost, quality, effectiveness, and outcomes of
alcohol services.  Descriptive studies of managed care systems, such
as case studies, surveys, resource allocation studies and secondary
analyses utilizing existing claims and other databases are
encouraged.  Prospective studies that examine a longer term impact
(3-5 years) of managed care systems on a patient cohort are also
encouraged.  It is important to note that studies evaluating
screening procedures or treatment interventions outside the context
of a managed health care system will not be considered responsive to
the RFA.
The following list of  research questions is intended to illustrate
NIAAA research interests; topics that are not specifically mentioned
are not necessarily excluded from consideration
General Research Questions:
o  What are the major differences between carve-out and integrated
systems of managed care and how do these different arrangements
affect access, utilization, quality of care, cost, and effectiveness
of alcohol-related treatment?
o  How do the various organization and/or financing characteristics
of managed care systems affect access, utilization, quality of care,
cost and effectiveness of treatment?
o  How do benefit packages differ and in what way do different
benefit packages affect access, utilization, quality of care, cost,
and effectiveness of alcohol treatment services?  To what extent do
benefit packages provide supplemental or "wrap around" services to
patients with multiple needs?
o  What is the impact of case management approaches to managed care
on alcohol-related treatment provider behavior?  How do "gatekeepers"
influence access, quality, costs and outcomes of care?
o  How do specific models of "risk sharing" (e.g., full or partial
capitation) influence alcohol-related treatment provider behavior?
o  What is the impact of alcohol-related treatment guidelines
developed by managed behavioral health firms?
o  What is the impact of managed care on alcohol-related services
purchaser behavior?  Has the availability of managed care resulted in
changes in benefit structure?
o  What risk adjustment methods have been employed by managed care
programs for alcohol treatment services?
o  What is the impact of managed care arrangements on provider
practice patterns?
o  How do enrollee recruitment and disenrollment policies affect the
utilization, cost and effectiveness of alcohol treatment services?
o  What has been the impact of managed care on public sector alcohol
treatment services?
o  How do managed care systems integrate state-of-the-art alcohol
treatment technologies (e.g., brief intervention)?  What is the
impact of these strategies on the cost and effectiveness of alcohol
treatment services?
In addition, a number of specific research questions apply to some of
the principal variables that have been identified to be of interest
in this RFA,
Access to Care:
o  How is access to care defined, measured, and evaluated by
different managed care programs?   How do different managed care
arrangements affect access to alcohol treatment?  Is there a
differential impact for different subgroups (e.g., women, the poor)
or across different types of treatment modalities (e.g., inpatient,
detox, outpatient)?  How is access restricted (e.g., denial of
requests for care) or expanded (e.g., broader geographic network of
outpatient services)?
Utilization of Services:
o  How are client utilization rates measured and evaluated by
different managed care programs?  What types of utilization review
criteria and procedures are utilized, and what is their impact on
utilization of alcohol services?  What is the impact of different
managed care arrangements, particularly financing arrangements, on
utilization of alcohol services?  Are there differential impacts
among subgroups and across different treatment modalities?  What are
the administrative costs associated with utilization review and what
is the impact of different systems of utilization review on provider
morale, on treatment process, and on outcome?
Quality of Care:
o  How is quality of care measured and evaluated by different managed
care programs?  How are structural quality controls (e.g.,
staff/client ratios, provider certification, staff credentialing,
case management protocols, etc.) determined and implemented?  What
are the treatment protocols that are utilized, and to what extent do
these protocols address the chronic, recurring nature of alcohol
o  How are costs for alcohol services defined and computed across
different managed care programs?  How much do different types of
managed care programs reduce alcohol treatment costs, including
total, per episode, daily, patient, practitioner, and provider costs?
To what extent do managed care systems result in reductions of other
medical or social costs?  Are there differences in short term vs.
long term cost savings?  Do cost savings differ across different
patient population groups (e.g., low income, elderly)?   How do plan
benefit structure and administrative factors affect cost (e.g.,
exclusion of high risk patients, restrictions on amount of services)?
o  How is treatment effectiveness defined and operationalized by
different managed care systems?  How is treatment effectiveness
monitored over time?  How do different systems of clinical decision-
making and case management affect treatment outcomes?  What is the
impact of different systems of service delivery (e.g., integrated vs.
carve out models, use of EAP programs) on the effectiveness of
treatment?  Do managed care programs improve cost-benefits and cost-
effectiveness of alcohol and treatment programs?  What incentives do
providers and managed care organizations have to improve
It is the policy of the NIH that women and members of minority groups
and their subpopulations must be included in all NIH supported
biomedical and behavioral research projects involving human subjects,
unless a clear and compelling rationale and justification is provided
that inclusion is inappropriate with respect to the health of the
subjects or the purpose of the research.  This new policy results
from the NIH Revitalization Act of 1993 (Section 492B of Public Law
103-43) and supersedes and strengthens the previous policies
(Concerning the Inclusion of Women in Study Populations, and
Concerning the Inclusion of Minorities in Study Populations), which
have been in effect since 1990. The new policy contains some
provisions that are substantially different from the 1990 policies.
All investigators proposing research involving human subjects should
read the "NIH Guidelines For Inclusion of Women and Minorities as
Subjects in Clinical Research," which have been published in the
Federal Register of March 28, 1994 (FR 59 14508-14513) and reprinted
in the NIH Guide for Grants and Contracts, Volume 23, Number 11,
March 18, 1994.
Investigators also may obtain copies of the policy from the program
staff listed under INQUIRIES.  Program staff may also provide
additional relevant information concerning the policy.
Prospective applicants are asked to submit by March 15, 1996, a
letter of intent that includes a descriptive title of the proposed
research, the name, address, and telephone number of the Principal
Investigator, the identities of other key personnel and participating
institutions, and the number and title of the RFA in response to
which the application may be submitted.
Although a letter of intent is not required, is not binding, and does
not enter into the review of a subsequent application, the
information that it contains allows NIAAA staff to estimate the
potential review workload and to avoid conflict of interest in the
The letter of intent is to be sent to:
RFA AA-96-001
Office of Scientific Affairs
National Institute on Alcohol Abuse and Alcoholism
Willco Building, Room 409
6000 Executive Boulevard, MSC 7003
Bethesda, MD  20892-7003
FAX:  (301) 443-6077
The research grant application form PHS 398 (rev. 5/95) is to be used
in applying for these grants.  These forms are available at most
institutional offices of sponsored research; from the Office of
Grants Information, National Institutes of Health, 6701 Rockledge
Drive, MSC 7910, Bethesda, MD 20892-7910, (301) 710-0267, Email:
girg@drgpo.drg.nih.gov; and from NIAAA staff listed under INQUIRIES.
The RFA label available in the PHS 398 (rev. 5/95) application form
must be affixed to the bottom of the face page of the application.
Failure to use this label could result in delayed processing of the
application such that it may not reach the review committee in time
for review.  In addition, the RFA title and number must be typed on
line 2 of the face page of the application form and the YES box must
be marked.  Applicants for support mechanisms other than R01 (i.e.,
an R29) must cite the relevant program announcement on line 2 in
addition to listing the current RFA.  Applications for FIRST Awards
(R29) must include three letters of reference.  Page limits and
limits on size of type are strictly enforced.  Non-conforming
applications will be returned without being reviewed.
Applicants from institutions that have a General Clinical Research
Center (GCRC), funded by the NIH National Center for Research
Resources, may wish to identify the Center as a resource for
conducting the proposed research.  If so, a letter of agreement from
either the GCRC program director or principal investigator should be
included in the application material.
Submit a signed, typewritten original of the application, including
the checklist and three signed photo copies in one package to:
6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)
At the time of submission, two additional copies of the application
must also be sent to:
RFA AA-96-001
Office of Scientific Affairs
National Institute on Alcohol Abuse and Alcoholism
Willco Building, Room 409
6000 Executive Boulevard, MSC 7003
Bethesda, MD  20892-7003
Bethesda, MD  20852 (for express/courier service)
FAX:  (301) 443-6077
Applications must be received by April 11, 1996.  If an application
is received after that date, it will be returned to the applicant
without review.  The Division of Research Grants (DRG) will not
accept any application in response to this RFA that is essentially
the same as one currently pending initial review, unless the
applicant withdraws the pending application.  The DRG will not accept
any application that is essentially the same as one already reviewed.
This does not preclude the submission of substantial revisions of
applications already reviewed, but such applications must include an
introduction addressing the previous critique.
Upon receipt, applications will be reviewed for completeness by DRG
and for responsiveness by the NIAAA.  Incomplete applications will be
returned to the applicant without further consideration.  If the
application is not responsive to the RFA, DRG staff may contact the
applicant to determine whether to return the application to the
applicant or submit it for review in competition with unsolicited
applications at the next review cycle.
Applications that are complete and responsive to the RFA will be
evaluated for scientific and technical merit by an appropriate peer
review group convened by the NIAAA in accordance with the review
criteria stated below.  As part of the initial merit review, all
applications will receive a written critique and undergo a process in
which only those applications deemed to have the highest scientific
merit, generally the top half of applications under review, will be
discussed, assigned a priority score, and receive a second level
review by the appropriate national advisory council or board. The
second level of review will be provided by the National Advisory
Council on Alcohol Abuse and Alcoholism.
Review Criteria
Criteria to be used in the scientific and technical merit review of
grant applications submitted under this RFA will include the
1. The scientific, technical, health or medical significance, and
originality of the proposed research to the goals of this RFA.
2. The appropriateness and adequacy of the research design and
methodology proposed to carry out the research.
3. The adequacy of the qualifications (including level of education
and training) and relevant research experience of the principal
investigator and key research personnel.
4. The feasibility of implementing the project (including recruitment
of subjects, implementation of the intervention or innovation,
cooperation of relevant organizations, and/or availability and
quality of necessary data).
5. The availability of adequate facilities, general environment for
the conduct of the proposed research, other resources, and
collaborative arrangements necessary for the research.
6. The appropriateness of budget estimates and duration in relation
to the proposed research.
7. Adequacy of plans to include both genders and minorities and their
subgroups as appropriate for the scientific goals of the research.
Plans for the recruitment and retention of subjects will also be
The initial review group will also examine the provisions for the
protection of human subjects and the safety of the research
Additional review criteria and eligibility requirements for FIRST
Awards (R29) are contained in the FIRST program announcement (revised
February 1994).
Applications recommended for approval by the National Advisory
Council on Alcohol Abuse and Alcoholism will be considered for
funding on the basis of the overall scientific and technical merit of
the proposal as determined by peer review, NIAAA programmatic needs
and balance, and the availability of funds.
Inquiries concerning this RFA are encouraged.  The opportunity to
clarify any issues or questions from potential applicants is welcome.
Direct inquiries regarding applications under this RFA to:
Frances Cotter, M.P.H.
Division of Clinical and Prevention Research
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard, MSC 7003
Bethesda, MD  20892-7003
Telephone:  (301) 443-0786
FAX:  (301) 443-8774
Emial:  fcotter@willco.niaaa.nih.gov
Direct general inquiries regarding health services research to:
Robert B. Huebner, Ph.D.
Division of Clinical and Prevention Research
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard, MSC 7003
Bethesda, MD  20892-7003
Telephone:  (301) 443-0786
FAX:  (301) 443-8774
Email:  bhuebner@willco.niaaa.nih.gov
Direct inquiries regarding fiscal matters to:
Linda Hilley
Grants Management Branch
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard, MSC 7003
Bethesda, MD  20892-7003
Telephone:  (301) 443-0915
FAX:  (301) 443-3891
Email:  lhilley@willco.niaaa.nih.gov
This program is described in the Catalog of Federal Domestic
Assistance, No. 93.273.  Awards are made under the authorization of
the Public Health Service Act, Sections 301 and 464H, and
administered under the PHS policies and Federal Regulations at Title
42 CFR Part 52 and 45 CFR Part 74.  This program is not subject to
the intergovernmental review requirements of Executive Order 12372 or
Health Systems Agency Review.
The Public Health Service (PHS) strongly encourages all grant
recipients to provide a smoke-free workplace and promote the non-use
of all tobacco products.  In addition, Public Law 103-227, the
Pro-Children Act of 1994, prohibits smoking in certain facilities (or
in come cases, any portion of a facility) in which regular or routine
education, library, day care, health care or early childhood
development services are provided to children.  This is consistent
with the PHS mission to protect and advance the physical and mental
health of the American people.
Callahan, JJ., Shepard, D.S., Beinecke, R.H., Larson, M.J., and
Cavanaugh, D. Evaluation of the Massachusetts Medicaid Mental
Health/Substance Abuse Program.  Report prepared for the Mental
Health/Substance Abuse Program, Massachusetts Division of Medical
Assistance.  Prepared by Heller School, Brandeis University, Waltham,
MA.  January 24, 1994.
Frank, R.G., McGuire, T.G., Newhouse, J.P. (in press). Risk contracts
in managed mental health care.  Health Affairs.
Freud, D.A., and Hurley, R.E. Medicaid managed care:  contribution to
issues of health reform.  Annual Reviews of Public Health,
16:473-495, 1995.
Garnick, D.W., Hendricks, A.M., Dulski, J.D., Thorpe, E.E., and
Horgan, C.M. Characteristics of private-sector managed care for
mental health and substance abuse treatment. Journal of Hospital and
Community Psychiatry,45(12):1201-1205, 1994.
Goldman, W. (1993). Claims experience of seven managed behavioral
health clients. Emeryville, CA: U.S. Behavioral Health.
Mechanic, D., Schlesinger, M., and McAlpine, D.D. Management of
mental health and substance abuse services:  State-of-the-art and
early results. The Milbank Quarterly, 73(1):19-55, 1995.
Oss, M (March, 1995). Open Minds, 12.

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