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.     

Improving quality in psychotherapy.

Discusses quality improvement (QI) in psychotherapy, and suggests that the managed care movement may have the effect of stimulating higher quality outpatient care. QI may stimulate better compliance with treatment protocols. Academic clinical psychology has produced treatment protocols and indicators of good psychotherapy but these may be ignored by the practicing psychotherapist as unwieldy and impractical. Continuous QI is a behavioral data-driven technology that can be applied to mental health services. The present article gives an example of nonadversarial data-driven process and outcome improvements. A shift of paradigm toward feedback loops in psychotherapy, collecting data on therapeutic change, and patient satisfaction at each session guide therapy. Data collected may help guide the individual sessions and can be collected to establish a dose–effect relationship for a particular therapist, or for a clinic or group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost savings from home and community-based services: Arizona's capitated Medicaid long-term care program

The Arizona Long-Term Care System is the first capitated, long-term care Medicaid program in the nation to operate statewide. It promotes an extensive home and community-based services program intended to lower long-term care costs by substituting home care for institutional care. Because the program is statewide, finding a suitable control group to evaluate it was a serious problem. A substitute strategy was chosen that compares actual costs incurred to an estimate of what costs would have been in the absence of home and community-based (HCB) services. To estimate the likelihood of institutionalizing clients in the absence of HCB services, coefficients for institutionalization risk factors were estimated in a logistic regression model developed using national data. These were applied to characteristics of Arizona clients. The model assigned approximately 75 percent of the program's clients to a category with traits that were determined to resemble nursing home residents' traits. A similar methodology was used to estimate lengths of nursing home stays. Lengths of stay by the program's nursing home patients were regressed on their characteristics using an event history analysis model. Coefficients for these characteristics from the regression analysis were then applied to HCB services clients to estimate how long their nursing home stays would have lasted, had they been institutionalized. These estimated nursing home stays were generally shorter than these same patients' observed home and community stays. Risk of institutionalization was then multiplied by estimated length of stay and by monthly nursing home costs to estimate what costs would have been without the HCB services option. The expected costs were compared to actual costs to judge cost savings. Home and community-based services appeared to save substantial amounts on costs of nursing home care. Estimates of savings were very robust and did not appear to be declining as the program matured. Savings probably came from several sources: the assessment teams that judged client eligibility were employed by a state agency and thus were independent from the program contractors; clients were required to be in need of at least a three-month nursing home stay; a cap was placed on the number of HCB services clients contractors were allowed to serve each month; the capitated payment methodology forced managed care contractors to hold down average HCB services costs or lose money; and the HCB services and nursing home costs were blended in the capitated rate, so that plans that failed to place clients in HCB services would lose money by using more nursing home days than their monthly capitated rate allowed.     

Research, practice, and managed care.

Examines the relationship between practitioners, researchers, and managed care. Managed care systems' basic purpose is to conserve as much as possible the health care dollar, and to provide rationale for the equitable distribution of public funds. Despite evidence that psychotherapy is an effective treatment, this well-documented conclusion continues to be assailed. Research has been used as a tool for undergirding the rationing of therapeutic services. Similarly, the demand for treatment manuals has been met and treatment manuals have been shown to be of value, although the value is limited. In the same vein, time-limited forms of therapy can produce change, but such changes will in most cases be modest. The author notes that it is one thing to recognize that in the face of a shrinking health care economy professionals must accept more or less severe restrictions imposed on their activities. However, it is quite another to create the impression that brief or time-limited forms of psychotherapy are fully comparable or even superior to more intensive and extended forms. There is also reason to believe that well-trained experienced therapists are superior service providers. The need for greater tolerance and realism in accepting what psychotherapy can and cannot do is emphasized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders

OBJECTIVES: This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care. METHODS: Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients. RESULTS: Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients. CONCLUSIONS: In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.     

Managed care: Is it the corpse in the living room? An exposé.

Examines the intrusion of managed care into the psychotherapeutic dyad from the perspective of a practicing psychologist. The author draws from established psychological theory and research and personal experience to expose the deleterious effects of managed mental health care. Triangulation, transference, ethics, economics, and client and therapist welfare as they relate to psychologists' overidentification with the medical industry are discussed. It is noted that while medical costs have skyrocketed in recent years, outpatient psychotherapy costs have little to do with the soaring cost of health care. Health care reform concepts that attenuate the 3rd-party diagnosis imperative are examined. A grass-roots movement of the psychological profession toward autonomy and better client- and self-care is necessary. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

Research contributions to improving managed health care outcomes.

Managed health care programs are beginning to look to findings from psychotherapy outcome research to help set policy, suggesting the need to consider outcomes research from the standpoint of usability or utility. It also provides an opportunity to integrate science and practice. Considering and applying outcomes in this context requires cooperation between scientists and practitioners, the willingness of each group to set aside guild agenda, and giving up favored but insupportable beliefs and practices on the parts of those in both scientist and practitioner camps. This type of cooperation may have mutual payoffs. This article considers some of the obstacles to this type of sacrifice and evaluates some of the potential costs of cooperating. It also provides perspectives on the new roles of psychological assessment and methods of outcome research that would provide a scientific basis for the function of managed health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychology and the Carter Administration.

Due to the spiraling costs of health care, it is likely that a comprehensive program of national health insurance will be enacted under the Carter Administration. Mental health services will be included as a primary health benefit. Psychologists should spend their energies not arguing whether psychotherapy is a health service, but instead insuring that psychology is independently recognized under national health insurance. Otherwise, it should be expected that all training support will soon be phased out and that the profession will cease to exist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed behavioral health services for children under carve-out contracts

OBJECTIVE: Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults. METHODS: Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization. RESULTS: Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children). CONCLUSIONS: The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.     

The Fort Bragg demonstration and evaluation.

Discusses the Fort Bragg study (L. Bickman, see record 83-31861; L. Bickman et al, 1995), the results of which call into question strongly held convictions about the ways mental health services should be structured. The study found no evidence of better clinical outcomes or reduced costs from such things as unlimited access, continuity of care, freedom from benefit limitations, availability of a full range of services, case management, and managed care. The author suggests that the negative conclusions were inevitable given the way in which the demonstration's mental health services were structured and provided. On closer examination, it is clear that the study was not really a model of managed care, there were no financial incentives to use resources or services cost effectively, and the providers were not only rewarded for doing more, but also did not appear to be changing their traditional practice patterns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The future of existential-humanistic psychotherapy.

Discusses potential contributions of the existential-humanistic orientation in psychotherapy. It is argued that only this type of therapy can replace emptiness with fulfillment and meaning and thus engender authentic, creative solutions to the challenges of this age. It is hoped that short-term, problem-centered treatment services offered by managed health care agencies will stimulate a desire for more life-changing therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Breaking free of managed care: A step-by-step guide to regaining control of your practice.

Reviews the book, Breaking free of managed care: A step-by-step guide to regaining control of your practice by Dana C. Ackley (see record 1997-97500-000). This book provides a practitioner's blueprint for moving from dependent (on managed care) to independent practice. It is organized around three major themes: 1) dealing with managed care; 2) the business of managed care-free therapy; and 3) the array of psychotherapists' services. The reviewer points out that the author tends to overlook some problem areas in psychotherapy. In addition, he takes some of his own skills as a doctoral-level clinical psychologist for granted and fails to appeal to practitioners with minimal training or expertise. However, overall, the reviewer believes that this is a highly enjoyable and practically useful book which provides some guidance to practitioners wanting to "break free from managed care." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fear and loathing on the managed care trail: A response to Pipal (1995).

Responds to the critique by J. E. Pipal (see record 1996-12808-001) of managed care. Pipal is criticized for hyperbole and negativity in her discussion, and it is suggested that professional and public-health objectives will be better served by an open and mutually respectful discussion that raises issues and seeks solutions to complex problems. It is argued that true managed care, featuring arrangements to regulate the costs, site, and utilization of mental health services in an ethically, fiscally, and clinically sound manner, would be a worthwhile goal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of the growth of managed care on academic medical centers and graduate medical education

The author offers insights into how the proliferation of competitive health care financing and service delivery systems based on managed care affects the financial support available to academic medical centers (AMCs), especially to their programs in graduate medical education (GME). The paper is based largely on case studies of AMCs conducted by the author in the summer of 1994 in the health care markets of San Diego, California, Minneapolis-St. Paul, Minnesota, and Washington, D.C., complemented by a review of the literature. In sum, the investigator found consensus among all parties that in the current market, managed care plans neither are willing nor feel able to pay much, if any, premium for the services of AMCs, particularly when established, respected alternatives exist, as they typically do for most services in major urban markets. Relatively few short-term adverse effects on AMCs were found from the growth of competitive systems, but AMCs are nevertheless very concerned that managed care will put them at a disadvantage. They are thus seeking ways to position themselves for the future. The AMCs are concerned that at some point, the cost reductions they are making will hinder the fulfillment of their unique traditional mission, since they believe that the costs of their GME programs can be reduced only so far without harming residents' training. Many managed care plans, however, question the AMC mission, taking issue particularly with the training AMCs provide and its relevance to current needs for primary and ambulatory care. The investigators also found considerable support for pooled funding for GME among diverse parties, but no consensus on how this funding should be structured, who should receive it, or what it should support. Potential conflicts were also identified between national, state, and market objectives for provider supply and specialty distribution because these objectives can embody different criteria for assessing the handling and locations of specialists' training. In addition, the findings indicate that it could be unwise to consider AMC policy independent of workforce objectives; doing so could create conflicts about the kinds of physicians who should be trained. The author concludes with a list of approaches to future research that may be constructive.     

Assessing bioethics today

Our society clearly needs to set limits on health care. The United States health care delivery system is the fourth largest economy in the world, yet its inflation continues to grow at twice the normal rate of other products and services. The inefficiencies are built in in such a way that while intensive care beds are plentiful, and very expensive, 37 million Americans cannot gain access to health care because they are either uninsured or underinsured. It is estimated that this figure will approach 39 million by the end of the decade. Since many of these individuals are young, the problem, it is said, has no real practical consequences because the young are relatively healthy. Yet evidence exists that the uninsured and underinsured receive poorer care than covered individuals. This and other inequities in the system have led many thinkers like Leonard Fleck to ask how just we must be in society. The answer to this question would presumably help us determine the lengths we must go in correcting the inequities. Even if the peace-dividend emerges from the new political events around the world, and we are able to spend more of our money on health care, our resources are not a bottomless pit. If need alone drives the system, just performing open-heart surgery on everyone who needs it would cost more than the annual budget itself. Virtually everyone agrees, then, that escalating health care costs are a moral problem because justice is involved, a political problem because public interest is involved, and that limits must be set that are moral and public.     

Psycotherapy, managed care, and the economy of interaction

This paper examines the disclosure over the value of long-term psychotherapy in a managed-care system. Many managed-care companies define extended psychotherapy as superfluous. Those who defend psychotherapy respond that the restrictions imposed by managed care are misguided and potentially harmful. After briefly discussing the relevant literature, the points of contention between psychotherapy and managed care are examined from the perspective of narrative literary theory. The analysis highlights the contrasting narrative assumptions implied about the importance of the clinical interaction. Pointing out each side's use of point-of-view, narrative structure, and informational exchange, it is posited that beneath arguments that often focus on the commodities of time and money lie larger, conceptual differences. These stealthily serve to undermine the possibility of a rational debate. The paper concludes by asserting that psychotherapy and managed care assume incommensurate narratives of interaction when discussing the value of therapy. The terms of discourse must be expanded in order to account for the philosophical differences described. Several ways this might be accomplished are proposed.     

Factors influencing survival after gamma knife radiosurgery for patients with single and multiple brain metastases

BACKGROUND: Significant changes are restructurng the U.S. health care delivery system. National health reform is now extending itself into the public sector. Increased health and medical costs by federal and state governments are forcing a reevaluation of major entitlement programs, especially Medicaid. METHODS/RESULTS: Because Medicaid is the single largest item in many state budgets, states are now enrolling Medicaid patients into managed and coordinated care arrangements as a means to control costs and increase access to care. HMOs are not only competing for private patients but also actively seeking the Medicaid population. Nationally, almost one-fourth of all Medicaid patients are now enrolled in managed care plans. Various models and approaches have been developed by individual states. CONCLUSIONS: Because managed care enrollment in the Medicaid program has increased substantially in recent years, selected services including vision care are no longer rendered by any practitioner willing to accept Medicaid fees. Freedom of choice is now restricted to pre-selected and panel practitioners participating with the managed care program. The rules, regulations, billing procedures, fees, and program requisites will differ under managed care programs. Private optometric practitioners must consider entering economic and organizational relationships and linkages that make them attractive to managed care organizations.     

Managed care, brief therapy, and therapeutic integrity.

A major cost-containment strategy of managed mental health care is the mandating of short-term psychotherapy via session limits, dollar caps on mental health benefits, and utilization review mechanisms. It is argued that while brief therapy is a widely useful treatment modality, when it is mandated by a 3rd party it violates the fundamental integrity of the therapeutic relationship. The construct of therapeutic integrity is defined, and the parameters vulnerable to managed care intrusions are identified. The author examines the implications of this analysis for (1) the practice of brief therapy, (2) training in brief therapy, (3) managed care, and (4) organized psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of screening versus nonscreening on treatment authorization in a managed care setting.

Many psychologists believe that screening evaluations required for treatment authorization are merely mechanisms to restrict needed patient care. Managers of behavioral health organizations, in contrast, fear that providers will misdiagnose patients to ensure reimbursement for unneeded services if not monitored. This study compared the managed behavioral health organization screening evaluation with direct therapist referral in terms of treatment eligibility determination. Only 5% of patients in the nonscreened group failed to meet diagnostic requirements for insurance reimbursement compared with 22% in the screened group. However, patient dropout was nearly double for the nonscreened group as compared with the screened group. The importance for psychologists to render well-documented, unbiased diagnoses of their patients is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)