State health care reforms: how they affect children and adolescents with emotional disorders and their families

This article reports on the Health Care Reform Tracking Project, a national study designed to describe and analyze state health care reforms and their impact on children and adolescents with emotional disorders and their families. It summarizes the results of the baseline survey of states conducted in 1995, exploring the nature and extent of the reforms in which states are engaged, most of which involve applying managed care technologies to their Medicaid programs. Trends across states are identified with respect to mental health service delivery, particularly with respect to children and adolescents. The article concludes with a discussion of issues and concerns related not only to mental health service delivery for children and adolescents with emotional disorders and their families but also to the systems of care that have been developing over the past decade to serve them. Some of these concerns include the lack of pilots or demonstrations, limited mental health coverage in some reforms, the lack of integration between mental health and substance abuse systems, the lack of special provisions for children, the need for more reliable bases for deriving capitation rates, the limited incorporation of systems of care, the need to incorporate interagency treatment planning and service delivery approaches, the lack of outcome measures specific to and appropriate for children, and the need for greater family involvement in the planning and implementation of these reforms.     

Managed care credentialing of advanced practice nurses

The enormous and rapid changes taking place in health care delivery are forcing institutions, organizations, and individual providers of care to reexamine their relationships and create new methods of assuring both quality of care and safety for consumers. One result has been the emphasis on systematic methods of credentialing, privileging, and measuring and evaluating an individual's qualifications and actual performance. This article discusses the credentialing and privileging processes that are either in place or evolving for physicians in the managed care health care systems. With the continued evolution of managed care in this country, advanced practice nurses may need to expand their credentialing process. This article provides information on the evolutionary events leading to credentialing and privileging, current and anticipated credentialing measures, sources of measurements, medicolegal issues, and suggestions for expansion of nurse credentialing. A comprehensive credentialing system will provide additional evidence of the nursing profession's capacity to play a major role in the reformed health care system.     

What focus groups suggest about mental health parity policymaking.

In 1994 Maryland passed a mental health parity law. Although the law specified minimums for insurance coverage, it allowed insurers to deny payment if treatments were not medically necessary or through a process of managed care. To learn more about the impact of this law, we conducted 5 focus groups composed of people involved in mental health care in Maryland. The groups suggested that the law was a small step in the direction of improving access to mental health care. However, they also indicated that parity legislation might do better to the extent that such bills provide for monitoring of medically necessary and managed-care provisions and, if warranted, improve them. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A monoarthritis model in rabbits induced by repeated intra-articular injections of lipopolysaccharide

In recent years, states have increasingly turned to managed care arrangements for financing and delivering health services to Medicaid beneficiaries. In 1996, approximately 40% of all Medicaid recipients were enrolled in some form of managed care. The rapid escalation of managed care in this population has been fueled by states' desire to slow the growth of Medicaid expenditures and by the trend toward managed care enrollment in the private health insurance industry. The effect of managed care on cost containment in the Medicaid program may be limited, however, because 85% to 90% of Medicaid managed care enrollees are women of childbearing age and children, who together account for 69% of Medicaid recipients, but only 26% of program costs. Nonetheless, the increase in managed care enrollment in this population may have a profound impact on health service delivery and health outcomes for U.S. children, approximately 20% of whom received health benefits through the Medicaid program in 1995. In the future, the proportion of Medicaid-eligible children enrolled in managed care will likely increase as a result of recent legislation that relaxed the requirement that states seek federal approval prior to mandating managed care enrollment for Medicaid beneficiaries. More states are relying on fully capitated arrangements as the preferred type of managed care for Medicaid recipients, despite the relative lack of experience many of these plans have in serving this low-income population. Moreover, managed care organizations have few incentives to enroll chronically or disabled children with higher-than-average expected costs. Without mechanisms in place that adequately adjust capitated rates to account for these higher-cost enrollees, managed care organizations may lose money, and children with the greatest health care needs may be underserved. As mandatory managed care enrollment for Medicaid recipients increases nationwide, states should carefully monitor changes in program costs and quality as well as implications for the delivery of pediatric health services and health outcomes.     

Secrecy, anonymity, and deception in donor insemination: a genetic, psycho-social and ethical critique

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.     

Maternal and perinatal health in Mali, Togo and Nigeria

When healthcare executives speak of managed care, they often use the term generically to refer to any arrangement with a healthcare payer other than traditional fee-for-service reimbursement. All too often, the "management" aspect is missing from managed care, resulting in an arrangement that could more aptly be described as "discounted care." This lack of clinical representation is unfortunate, since there are numerous issues that have an impact on clinical care, including choice of referral providers, noncoverage of certain procedures or treatments, and similar issues that may influence the patient's plan of care. Organizations that approach managed care as a system that blends the resources of management, finance, and clinicians, will enjoy the greatest potential for success. With their practical experience and insight into the administrative and clinical issues that may be encountered, nurse case managers will ultimately be responsible for managing the care of the contracted population. As case managers are the vital link among payers, providers, patients, and families, it is essential that the case manager understand managed care concepts, be conversant in the terminology of managed care, function as a member of the team responsible for evaluating contracts, and periodically review existing arrangements. This article presents an overview of the managed care contract development process, and provides tools to enable the nurse case manager to participate in the contracting process.     

Pharyngeal wall vibration detection using an artificial neural network

OBJECTIVES: To assess the likelihood of health care legislation in the forthcoming 105th Congress in 5 areas: health care coverage, tax and Employee Retirement Income Security Act (ERISA) policy, Medicaid, Medicare, and managed care. DESIGN: Informal, semistructured conversations that took place in the months prior to the 1996 elections. POPULATION: Congressional health staff and administration officials. OUTCOME MEASURES: Unofficial, off-the-record personal opinions. RESULTS: Health care coverage initiatives to benefit children and unemployed persons are likely to be proposed, but have little chance of enactment; children are seen as well provided for under current Medicaid law, the strong economy and high employment levels lower concern for unemployed issues, and the effort required to pass the Kassebaum-Kennedy legislation needs time to settle. Tax proposals, such as medical savings accounts (MSAs), and ERISA amendments have no constituency; also, the MSA demonstration in Kassebaum-Kennedy will forestall further action. Medicaid is far less an issue than in the previous Congress, because spending has fallen unexpectedly, the bitter fight over block grants makes them unlikely to be revisited, and the administration is likely to enhance state flexibility through waivers. Medicare will be the subject of substantial action to defer impending insolvency temporarily, but there is virtually no chance that definitive long-term solutions will be enacted even though the underlying fiscal problems are thoroughly understood and recognized. Managed care will be the venue for numerous proposals designed to address specific consumer and quality issues. CONCLUSIONS: Four bitter years of fighting over health care issues has raised awareness of the problems, but has produced a political chemistry that is too rancorous to permit passage of significant legislation in the near future.     

Survey of Medicaid child dental services in Washington state: preparation for a marketing program

The authors surveyed Washington state dentists to gain an understanding of their participation in the Medicaid dental program, their willingness to learn more about the program and the degree of importance they attached to preventive care for preschool-aged children. They found that concerns about fees and administrative aspects predominated and concerns about client behaviors were expressed less often. Many dentists indicated a willingness to learn more about the program. These findings will be used to develop a plan to market the Medicaid program to Washington state dentists.     

Managed care contracts and negotiations

This article examines the key provisions which should be focused on when reviewing managed care contracts. It offers guidance on how gastroenterologists can negotiate more favorable terms and avoid common contracting pitfalls. The article also highlights specific issues applicable to capitated and other risk-sharing arrangements.     

Parents with human immunodeficiency virus infection: perceptions of their children's emotional needs

OBJECTIVE: To investigate the likelihood of patients who have human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) being parents and to identify concerns of these parents about their children. DESIGN: A survey was conducted of parental status, demographics, perceptions of social/emotional needs of self and one's children. Responses were analyzed for demographic differences. PARTICIPANTS: A total of 242 patients from the university HIV/AIDS clinics completed the survey. MAIN OUTCOME MEASURES: Parental status, number, and ages of children, parental concerns about their children related to their own HIV/AIDS: RESULTS: Nearly one third (31.8%) of the sample of HIV/AIDS patients were parents, and three fourths (76%) of the female patients were mothers. Slightly more than one third of these were married, and these were not predominantly families who also had infected children. The percentage of women in the parent subsample (40.8%) was higher than the percentage of women in the overall patient sample (16.7%). Only half of the parents reported that their children > 4 years of age knew of their diagnosis. Two thirds of the parents reported they believed their children did not need to talk to someone about their parent's health, and nearly half of the parents reported that they did not need help dealing with their children concerning issues related to AIDS. CONCLUSION: The percentage of HIV/AIDS patients who are parents is high, and parental status and emotional needs of parents and their children will likely become an increasingly important issue. Many questions are raised by our findings. Should we be concerned that many parents have been unable to talk to their children about their own health? Should we help parents acknowledge that their children may need some outside help to cope?     

Changing technology in health: product liability

Greater health consumer awareness and increasing levels of concern for the rights of patients have led to patient care technology being more strictly regulated. This article analyses both the general law issues and the particular statutes that will be of relevance to those involved in evaluating and implementing such technologies. There are three main elements to this analysis. Firstly, there is the issue of liability for a product fault, which will in many cases be directed by legislation back to the manufacturer of the goods. Secondly, those involved in placement of patient care technology should be aware of anti-discrimination legislation when making placement decisions. Finally, occupational health and safety legislation sets minimum standards for technology used in healthcare facilities. The author suggests ways of complying with the laws for each regulatory regime.     

Joining forces for children's health

From airborne particulatesto pesticide-laden fruit, children probably encounter more pollutants than adults. Because their bodies are rapidly developing, children may react more strongly to these toxins, too. The NIEHS hopes to learn more about how several hazardous agents specifically affect kids. Together, the NIEHS and the EPA are spending $10 million to establish up to six Centers for Children's Environmental Health and Disease Prevention Research. The CDC, a third partner,will later help apply center research to public health.     

Psychologists, Congress, and public policy.

As professional psychologists become increasingly involved in shaping health care policy in our nation, it is imperative that they understand the various forces that influence congressional members to enact legislation. This article examines two major issues: (a) Congress's cautious and restrained approach to health care policy and (b) preemption and the relationship between Congress and the states. Understanding these issues will enable psychologists to become more effective representatives of both the professional and societal interests of professional psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The media vs managed health care: are we seeing a full court press?

BACKGROUND: Despite the fact that medical coverage for many Americans is shifting rapidly from traditional insurance to managed care, studies suggest that most citizens have limited knowledge or understanding of the implication of this change. OBJECTIVE: To evaluate the predominant message being portrayed by the lay press on managed care. METHODS: We conducted a review of newspaper articles dealing with managed care from several leading national newspapers. Surveys, editorials, letters to the editor, or nonclinical articles were excluded. The articles were examined to evaluate their likely effect on the reader's willingness to join a managed care organization, and were scored using a standardized survey instrument. The final analysis included data from 85 articles from an original pool of 277. RESULTS: In only 8% of cases, the articles were considered likely to have had a positive influence on the reader and, thus, encourage them to join or remain with a managed care organization. More important, in fully two thirds of cases, we believed the articles portrayed so unfavorable a message that the reader was less likely to join, or might even decide to leave, a managed care organization. The articles dealt most frequently (67%) with patient concerns with managed care, focused mainly on cost and quality issues, and managed care representatives were the people whose opinions were most commonly (53%) solicited. CONCLUSIONS: It seems highly likely that public perception of managed health care will be influenced by the strongly negative representation being portrayed by the newspapers. While debate over the good vs bad features of managed care continues, available evidence suggests this form of health care coverage continues to grow. The press is likely to remain an important source by which information about managed care is transmitted to the public and will certainly influence public decision making on the issue. If the current negative representation continues, we may soon begin to see a widespread backlash of public opinion opposing this form of health care.     

Issues of death and dying: the perspective of critical care nurses

A major shift in the care of terminally ill people, due to advances in technology, and the development of legislation regarding patient self-determination and autonomy, has occurred over recent years. Critical care nurses (CCNs) are involved daily in issues of death and dying and are very aware of the needs, fears and psychosocial issues of patients and their families. Professional associations see a legitimate role for nurses in assisting the dying to achieve a dignified death. For legislation, policies and guidelines surrounding end-of-life issues to be effective, and to assist nursing staff with these sensitive, often difficult concerns, it is important that data on the opinions and perspectives of CCNs be objectively obtained. In a study by the Department of Social and Preventive Medicine at the University of Queensland, questionnaires were sent to 1100 randomly sampled community members and almost 1200 health professionals (nurses, general practitioners and specialists), including 299 CCNs. The response rate of CCNs to a 30-page postal questionnaire was 79 per cent (n = 231), indicating those nurses' high levels of interest in and/or concern regarding this area. CCNs supported the use of advance directives, the appointment of proxies and the need for doctors and nurses to give sufficient medication to relieve pain, even if this hastened the death of the patient. In addition, CCNs, more than any other professional group, supported the right of the terminally ill patient to physician-assisted suicide or euthanasia, their responses being very similar to those of community members. CCNs clearly face issues which, from legal, medical and ethical viewpoints, cause them concern. In sharing their personal experiences, CCNs stressed the need for more communication between doctors and patients, as well as between doctors and nurses. In addition, CCNs saw a clear role for themselves as advocates for patients/families in the decision-making process.     

Tracking consumers' reactions to the changing health care system: early indicators

A survey in fifteen communities and nationwide of consumers' opinions about changes in their local health care system reveals that Americans are surprisingly positive about recent changes in their personal access to and quality of care and consistently negative about changes in the cost of care. Although many consumers think that changes in the system are making things worse, they are optimistic about the trend toward managed care. Subgroup analysis shows that uninsured persons and persons with health problems reported high rates of concern about many of the health system issues we explored, while Medicaid recipients, Hispanics, and African Americans reported positive changes in their access to and quality of care.     

Managed care and reproductive health

Managed care poses special challenges to midwives providing reproductive health care. This is owing to the sensitive nature of issues surrounding reproductive health and aspects of managed care that may impede a woman's ability to obtain continuous, confidential, and comprehensive care from the provider of her choice. Variations across payers (ie, Medicare, Medicaid, and commercial insurers) regarding covered benefits and reimbursement of midwifery services also may create obstacles. Furthermore, some physicians and managed care organizations are embracing policies that threaten the ability of midwives to function as primary health care providers for women. Despite these hurdles, midwives have the potential to remain competitive in the new marketplace. This article underscores the importance of being knowledgeable about legislation and policy issues surrounding the financing of midwifery services, quality performance measurement for HMOs as they pertain to reproductive health, and discussions regarding which clinicians should be defined as primary care providers.     

Accreditation of the professional competence of intensive care unit nurses and their education]

The healthcare system must be driven by the needs of patients and their families. Keeping in mind the current nursing education system in the United States, the AACN Certification Corporation has designed a new model to refocus patient care activities so they can be defined according to the needs of patients and families wherever they may be. This model also addresses the credentialing of nurses with specialized knowledge and skills and may be adaptable as the conceptual framework for a national nursing specialty credentialing system in other countries.     

Psychological practice and managed care: Results of the CAPP practitioner survey.

Practicing members of the American Psychological Association (APA) were surveyed regarding their work settings, activities, and greatest professional concerns in the managed care era. Results from 15,918 licensed psychologists indicated that half were full-time independent practitioners engaged principally in psychotherapy and assessment and another third were in part-time private practice. Four out of five reported a negative impact of managed care on their practices. Concerns about changes to practice and ethical dilemmas as a result of managed care policies were common to all settings. Relatively few differences were apparent between earlier and more recent generations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Special Committee on Aging and the health care agenda in 1998.

Presents a report from the chairperson on the agenda and health issues for 1998 of the US Senate Special Committee on Aging. With Baby Boomers growing older and living longer than ever before, and with fewer children being born, attention to issues affecting older Americans is growing every day. These demographic trends will change the shape of our public and private retirement income and health arrangements over the next few decades. Topics on the committee's agenda include Medicare's Part A Hospital Trust Fund, the future financial viability of the Social Security retirement program, other long-term care concerns, and the investigation of consumer fraud targeting the elderly. Health issues discussed include the Kassebaum-Kennedy Health Insurance Portability and Accountability Act, employer-provided managed care plans, private contracting in Medicare, the tobacco settlement, and the uninsured. In conclusion, psychologists are urged to get involved in helping Congress make policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)