Search PubMed⌕ Search

Biomedical subjects

D Mechanic

Publications and source records attributed to D Mechanic.

At least 55 records · Page 3Linked to original sources
PubMed1996

Mental disorders in public, private nonprofit, and proprietary general hospitals.

OBJECTIVE: The authors' goal was to assess the effects of facility ownership on the characteristics of psychiatric inpatients treated in public, private nonprofit, or proprietary general hospitals. METHOD: Data from the 1993 National Hospital Discharge Survey were analyzed to determine the number, sociodemographic and diagnostic composition, and treatment characteristics of patients with primary mental disorders discharged from public, private nonprofit, and proprietary general hospitals. RESULTS: An estimated 1.83 million patients with a primary mental disorder diagnosis were discharged from general hospitals in 1993; the number of such discharges in the National Hospital Discharge Survey, which excluded federal general hospitals, was 13,086. These patients were unevenly distributed among public (9.4%), private nonprofit (78.9%), and proprietary (11.7%) hospitals. Psychiatric patients of public and private nonprofit hospitals were more likely to be diagnosed with schizophrenia (public: 23.4%, nonprofit: 18.8%, proprietary: 12.6%), a comorbid substance-related disorder (public: 29.9%, nonprofit: 31.0%, proprietary: 17.4%), a personality disorder (public: 11.6%, nonprofit: 11.3%, proprietary: 4.7%), or a general medical disorder (public: 62.4%, nonprofit: 57.4%, proprietary: 41.1%) than patients of proprietary hospitals. Uninsured psychiatric patients were far more common at public hospitals than at the other types of facilities (public: 17.0%, nonprofit: 9.9%, proprietary: 6.4%). CONCLUSIONS: Public general hospitals play an important role in caring for uninsured patients with severe mental illness. Before widespread closures occur in the public general hospital sector, it is critical that policy makers identify and develop resources to replace the care these institutions currently provide to poor patients with severe psychiatric disorders.

Adolescent↗
PubMed1996

Emerging issues in international mental health services research.

In developed nations, interest in mental health services research is increasing, which parallels an increased appreciation of the social and financial costs of mental illness and a growing need to identify cost-effective patterns of care. This paper examines common challenges in mental health services research, such as adjudicating between competing mental health priorities, designing research to better understand key elements in successful interventions, defining treatment outcomes more broadly to reflect consumer and family preference and quality of life, and linking services to improve community care. Using the assertive community treatment model as an example, the paper focuses on some of the differences between services research and controlled clinical investigations and the difficulties of looking inside the "black box" of effective interventions.

Community Mental Health Services↗
PubMed1996

Failure of health care reform in the USA.

The failure of health reform in the USA reflects the individualism and lack of community responsibility of the American political culture, the power of interest groups, and the extraordinary process President Clinton followed in developing his highly elaborate plan. Despite considerable initial public support and a strong start, the reform effort was damaged by the cumbersome process, the complexity of the plan itself, and the unfamiliarity of key components such as alliances for pooled buying of health insurance. In addition, the alienation of important interest groups and the loss of presidential initiative in framing the public discussion as a result of international, domestic and personal issues contributed to the failure in developing public consensus. This paper considers an alternative strategy that would have built on the extension of the Medicare program as a way of exploring the possibilities and barriers to achieving health care reform. Such an approach would build on already familiar and popular pre-existing components. The massive losses in the most recent election and large budget cuts planned by the Republican majority makes it unlikely that gaps in insurance or comprehensiveness of coverage will be corrected in the foreseeable future.

Cultural Characteristics↗
PubMed1996

Changing medical organization and the erosion of trust.

Trust in medicine contributes to effective communication, cooperation in treatment, and the ability to cope with uncertainties. Social trust in medicine reflects public attitudes and is shaped by media and current events. Interpersonal trust depends on the degree to which patients see their doctors as competent, responsible, and caring. The commercialization of medical care, conflicts of interest, media attention to medical uncertainty and error, and the growth of managed care all challenge trust. Trust is encouraged by patient choice, continuity of care, and encounter time that allows, opportunities for feedback, patient instruction, and patient participation in decisions. An informal inquiry of medical leaders indicates that most believe trust is eroding. Institutions are taking measures to help restore trust: eliciting patient feedback; providing more information for patients are the public; improving staff education and sensitivity training; paying attention to clinicians' interpersonal skills; sponsoring support groups; instituting patient empowerment projects; and focusing on ethics issues.

Continuity of Patient Care↗
PubMed1995

Dilemmas in rationing health care services: the case for implicit rationing.

With tension between the demand for health services and the cost of providing them, rationing is increasingly evident in all medical systems. Until recently, rationing was primarily through the ability to pay or achieved implicitly by doctors working within fixed budgets. Such forms of rationing are commonly alleged to be inequitable and inefficient and explicit rationing is advocated as more appropriate. Utilisation management in the United States and quasi-markets separating purchasing from provision in the United Kingdom are seen as ways of using resources more efficiently and are increasingly explicit. There is also advocacy to ration explicitly at the point of service. Mechanic reviews the implications of these developments and explains why explicit approaches are likely to focus conflict and dissatisfaction and be politically unstable. Explicit rationing is unlikely to be as equitable as its proponents argue and is likely to make dissatisfaction and perceived deprivation more salient. Despite its limitations, implicit rationing at the point of service is more sensitive to the complexity of medical decisions and the needs and personal and cultural preferences of patients. All systems use a mix of rationing devices, but the clinical allocation of services should substantially depend on the discretion of professionals informed by practice guidelines, outcomes research, and other informational aids.

Disclosure↗
PubMed1995

Studying inpatient treatment practices in schizophrenia: an integrated methodology.

A multi-phase research project examining current inpatient psychiatric practices and the relationships between different treatments and patient outcomes is described. The study sample includes Medicaid patients with a diagnosis of schizophrenia who have been treated in inpatient units of general hospitals in New York State. The research is focused at the heart of the debate concerning the appropriate role of inpatient psychiatric care within a balanced system of mental health services. Addressed are the conceptual issues that guided the project, research strategies, instrument development, measures used and the preliminary findings that informed successive phases. Design issues are reviewed in light of the conceptual and pragmatic decisions made with a multiple site design. A compelling argument is made about the need for a long-term treatment orientation that prepares patients for what lies ahead and that assures communication and continuity between inpatient and outpatient care.

Adolescent↗
PubMed1995

Emerging trends in the application of the social sciences to health and medicine.

Tensions are inevitable between funders seeking to solve specific health care issues within existing frameworks and many social scientists who see health and health care as reflections of societal stratification and processes of power and control. Many current and impending issues require deep scrutiny of values and meaning systems as they relate to class, gender, ethnicity and other forms of social differentiation. Interdisciplinary efforts provide social scientists important problem-solving opportunities but also occasions to refine disciplinary theories and methods. In recent years such efforts have resulted in increased sensitivity to demographic imperatives, prospective investigations, social experimentation, a growing appreciation of the complexity of life trajectories, development of more complex models of causation and remediation, and a revival of interest in meaning systems and their effects on ultimate outcomes. Social scientists have come to play a variety of roles in health services and policy research that contribute to a fruitful interplay of theory and practice. Major roles include helping to frame issues and how they are attacked; anticipating emerging trends, issues and problems; monitoring health and the provision of health services; evaluation and assessment; and implementation processes. The contributions of the social sciences to understanding complex organizational arrangements, structures, cultures, managerial approaches, financial arrangements and regulatory processes are increasingly evident and part of a culture of informed thinking.

Delivery of Health Care↗
PubMed1995

Sociological dimensions of illness behavior.

The almost exclusive dependence on the diagnostic disease model limits addressing the burden of illness and disability typically seen in primary medical care. With aging of populations and increasing prevalence of chronic disease and disability and behavioral disorders, new approaches to patient assessment and intervention are needed to extend traditional models. Using illness behavior as a point of departure, I examine the disability process and the types of considerations relevant to promoting function and maintaining patients' quality of life. At the individual level, alternatives include modifying impairments, increasing patient motivation and encouraging helpful attitudes, teaching coping strategies, identifying helpful assistive devices, educating family members and employers and providing support. A broader view also makes clear that varying aspects of the disability process are appropriate issues for social policy and environmental remediation. In examining various examples of the disability process, the paper focuses on self-appraisal and illness behavior and the way social movements help to define and redefine conceptions of illness and disability. Recognizing that the kinds of changes discussed will not come easily, the paper concludes with a discussion of trends encouraging broader practice orientations and the types of interventions that can be helpful in encouraging and reinforcing such developments.

Activities of Daily Living↗
PubMed1995

The Americanization of the British National Health Service.

The core reform of the British National Health Service (NHS) was the establishment of a quasi market with a split between purchasers and providers. Health authorities and general practitioner (GP) fundholders were to be discriminating purchasers seeking more efficient and responsive services. This market orientation was embedded in a larger context of managerial, allocational, public health, and primary care changes. This paper reviews the background and dynamics of these modifications and offers an early assessment. There is evidence that the reforms have unleashed much energy, activity, and thoughtfulness about future health care, but it remains unclear whether the gains justify the increased administrative and other transaction costs and potential threats to equal access.

Family Practice↗
PubMed1995

Management of mental health and substance abuse services: state of the art and early results.

Managed care (MC) refers to capitated practice (HMOs), utilization management (UM), and programs of case management for persons with mental illness and problems of substance abuse. These approaches differ substantially, and within each type are variations. Management of mental health and substance abuse services is increasingly prevalent, often sharply reducing costs. Savings result from reducing inpatient hospitalization and, sometimes, by substituting less expensive services for more costly ones. Most studies of managed care, however, measure costs narrowly, neglecting shifts in costs to patients, professionals, families, and the larger community. Strategies typical of HMOs and UM may result in lower-quality care for persons with serious mental illness and problems of substance abuse. Studies on this topic are reviewed, an analytic frame of reference is presented, and research needs are defined.

Cost Allocation↗
PubMed1995

Organizational aspects of caring.

Caring is fundamental to competence in medicine. Expressions of humaneness in the relationship between doctor and patient foster bonds of trust, enabling doctors and patients to communicate in ways that enhance diagnosis, treatment, and compliance. To be effective, a caring attitude must be adopted by all persons involved in the delivery of health care. Components of caring can be specified, learned, and incorporated into routine medical practice. Through their impact on stress management and coping, as well as morale and job satisfaction, the organizational and administrative practices surrounding health care encounters decisively impinge on caring. The organizational and financial arrangements for enhancing the humane delivery of health care are examined.

Attitude of Health Personnel↗
PubMed1994

Effects of illness attribution and depression on the quality of life among persons with serious mental illness.

Attributing one's problems to a mental illness is associated with reduced subjective quality of life (QOL) among persons with schizophrenia, controlling for a broad range of socio-demographic, social, clinical, and psychosocial variables. Persons who attributed their problems to a 'physical, medical, or biological' problem in contrast to a 'mental illness' reported more positive social relations and higher overall quality of life. Much of the negative effect of mental illness attributions is explained by perceived stigma, lower self-esteem, and a higher level of depressive symptomatology. Depressive symptoms have an independent negative effect on QOL net of all other variables. These findings have important implications for the appropriate rehabilitation of persons with mental illness and require further scrutiny with prospective data.

Adult↗
PubMed1994

Integrating mental health into a general health care system.

To implement the proposed Clinton mental health benefit for the year 2001 requires a capacity to manage a flexible, comprehensive benefit. If fragmentation of services and discontinuity of care are to be reduced, mechanisms must be developed to coordinate services among domains--between acute and chronic care, and among public and private providers. Evidence exists that basic mental health services generally can be managed in health maintenance organizations (HMOs) with considerable cost savings and without detrimental effects on health, but it is less clear whether this is true of services for persons with severe and persistent mental illness. Effective services for persons with severe disorders require a capacity to organize and manage services across broad medical and social areas, but anticipated costs encourage providers to narrow the scope of care they offer and to select low-risk patients. Much will depend on developing methodologies that allow providers to be reimbursed accurately in relation to risk and that protect small providers from the potential cost of acquiring too many high-risk patients.

Community Mental Health Services↗
PubMed1994

Establishing mental health priorities.

Mental health policy has evolved haphazardly, reflecting fragmentation of authority, competing ideologies, limitations of current knowledge and technologies, and changes in entitlements and insurance associated with health and welfare programs. While seeking parity with general health services, the mental health sector requires as well a range of health and social services that extends well beyond acute care, particularly for those with severe and persistent illness. Despite recent advances in articulating health, disability, and social services programs, much remains undone. The stigma of mental illness affects both intergovernmental cooperation and public response. Health reform provides an opportunity to address neglected areas and to build a closer connection with general health services. New coalitions of advocates for the mentally ill, the elderly, and persons with disabilities could construct a coherent long-term-treatment orientation that would benefit all.

Federal Government↗
PubMed1994

Psychiatric reimbursement reform in New York State: lessons in implementing change.

The failure of an innovative and ambitious reform in the psychiatric reimbursement system of New York State is examined for specific lessons of value for other states as they implement new payment strategies to encourage improved treatment of the mentally ill in general hospitals and community settings. The New York payment system was comprehensive, embracing both inpatient and outpatient care, and had significant support in the hospital and professional communities. Still, its impact on hospital performance was small and only partially consistent with its goals. For mental health reimbursement reform to succeed, state administrators must provide more clear, sustained, and forceful signals that take account of the real barriers to implementation; they must also ensure that the financial incentives and rewards are recognized by those who carry out the actions needed to translate goals into reality.

Episode of Care↗