Dilemmas of medical ethics in the Canadian Penitentiary Service.
There is a unique hospital in Canada-and perhaps in the world-because it is built outside prison walls and it exists specifically for the psychiatric treatment of prisoners. It is on the one hand a hospital and on the other a prison. Moreover it has to provide the same quality and standard of care which is expected of a hospital associated with a university. From the time the hospital was established moral dilemmas appeared which were concerned with conflicts between the medical and custodial treatment of prisoners, and also with the attitudes of those having the status of prisoner-patient. Dr Roy describes these dilemmas and attitudes, and in particular a special conference which was convened to discuss them. Not only doctors and prison officials took part in this meeting but also general practitioners, theologians, philosophers, ex-prisoners, judges, lawyers, Members of Parliament and Senators. This must have been a unique occasion and Dr Roy's description may provide the impetus to examine these prison problems in other settings. (+info
Behavioral health benefits in employer-sponsored health plans, 1997.
Data for 1997 show that three-quarters or more of employer-sponsored health plans continue to place greater restrictions on behavioral health coverage than on general medical coverage. The nature of these restrictions varies by plan type. Some improvement in the treatment of mental health/substance abuse (MH/SA) benefits in employer plans may be occurring, however. Comparisons with data from 1996 show that the proportion of plans with benefits for "alternative" types of MH/SA services, such as nonhospital residential care, has increased. Further, the proportion with special limitations on these benefits shows a modest decrease. (+info
Mental health/medical care cost offsets: opportunities for managed care.
Health services researchers have long observed that outpatient mental health treatment sometimes leads to a reduction in unnecessary or excessive general medical care expenditures. Such reductions, or cost offsets, have been found following mental health treatment of distressed elderly medical inpatients, some patients as they develop major medical illnesses, primary care outpatients with multiple unexplained somatic complaints, and nonelderly adults with alcoholism. In this paper we argue that managed care has an opportunity to capture these medical care cost savings by training utilization managers to make mental health services more accessible to patients whose excessive use of medical care is related to psychological factors. For financial reasons, such policies are most likely to develop within health care plans that integrate the financing and management of mental health and medical/surgical benefits. (+info
Mental health care in the primary health care setting: a collaborative study in six countries of Central America.
The results of a naturalistic epidemiological study conducted in 6 Central American countries in collaboration with the WHO/PAHO Regional Office are reported, aimed at describing the patients with mental distress presenting to the primary health care setting, the interventions enacted and the evolution of the patients over the 6 months following recruitment. A total of 812 patients were recruited by the personnel of 11 primary health care centres. A high degree of heterogeneity was observed with respect to the patients' characteristics and the patterns of care provided. The factors potentially contributing to the heterogeneity, identified through multivariate analyses, are discussed in detail against the specific background differences between countries and between areas within each country. Interestingly albeit expectedly, besides the differences in health care provision and availability, social needs appear to influence both interventions and outcomes. (+info
Looking beyond the formulary budget in cost-benefit analysis.
With the introduction of newer, more expensive psychotropic medications, healthcare providers and managed care administrators must consider whether these drugs offer "value for the money." A true picture of the benefits of these drugs emerges only when all the costs of treatment are considered. Focusing exclusively on the acquisition cost of the drug can result in a misleading impression of the drug's worth. Although the medication costs associated with treating a patient with a newer drug increase, use of these agents may actually result in an overall decrease in healthcare costs, through reductions in hospitalization and length of stay, use of mental health services, and prescriptions for adjunctive drugs. In one study of the newer antipsychotic agent risperidone, the overall annual costs of treating a patient with schizophrenia were reduced by nearly $8,000 (Canadian dollars), even though medication costs increased by approximately $1,200 (Canadian dollars). Retrospective and prospective pharmacoeconomic studies can provide valuable data on the cost effectiveness of treatment with newer psychotropic medications. (+info
Behavioral health services: carved out and managed.
This article highlights the financial pressures that led to an examination of how mental healthcare was provided and paid for, and discusses the rise, characteristics, and functioning of carved-out behavioral healthcare. The typical characteristics of managed behavioral health carve outs (MBHCOs), including contracts, payment arrangements, provider networks, and data collection are discussed and illustrated using the example of United Behavioral Health. The article details the function of the MBHCO on cost and utilization, access, quality, and the relationship of behavioral health services to general medical care and other human services, but cautions that further research is needed to evaluate the qualitative aspects of care. (+info
Mental disorders in the primary care sector: a potential role for managed care.
This activity is designed for leaders and managers of managed care organizations and for primary care physicians involved in evaluating, treating, and caring for patients with mental disorders. GOAL: To provide a better understanding of primary care patients' needs for mental health services and how managed care companies might best address these needs. OBJECTIVES: 1. Describe problems in detection of mental disorders 2. Discuss the specific ways in which treatments can be improved for mental disorders under managed care systems. (+info
A conflict of strategies: Medicaid managed care and Medicaid maximization.
OBJECTIVE: To examine the influence of state strategies aimed at increasing federal Medicaid matching dollars on the design of states' Medicaid managed care programs. STUDY DESIGN: Data obtained from the 1996-1997 case studies of 13 states to examine how states have adapted the design of their Medicaid managed care programs in part because of maximization strategies, to accommodate the many roles and responsibilities that Medicaid has assumed over the years. PRINCIPAL FINDINGS: Our study showed that as states made the shift to managed care, some found that the responsibilities undertaken in part through maximization strategies proved to be in conflict with their Medicaid managed care initiatives. Among other things, the study revealed that most states included provisions that preserved the health care safety net, such as adapting the managed care benefit package and promoting the participation of safety net providers in managed care programs. In addition, most of the study states continued to pay special subsidies to safety net providers, including hospitals and clinics. CONCLUSIONS: States have made real progress in moving a large number of Medicaid beneficiaries into managed care. At the same time, many states have specially crafted their managed care programs to accommodate safety net providers and existing funding mechanisms. By making these adaptations states, in the long run, may compromise the central goals of managed care: controlling costs and improving Medicaid beneficiaries' access to and quality of care. (+info