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Biomedical subjects

H H Goldman

Publications and source records attributed to H H Goldman.

At least 19 recordsLinked to original sources
PubMed1992

Psychiatric outpatient practice: patterns and policies.

OBJECTIVE: The purpose of this paper is to explore possible consequences of recent changes in the Medicare payment schedule for office-based psychiatric services. METHOD: Psychiatric office visits from the 1985 National Ambulatory Medical Care Survey were categorized in a manner that approximates commonly used codes of the Physicians' Current Procedural Terminology. An analysis was conducted of the frequency and clinical characteristics of various types of services, focusing particularly on visits of under 20 minutes in length that included a medication prescription (medication visits) and other visits of 35 minutes or less in duration (brief visits). RESULTS: Medication visits and brief visits together accounted for more than one-quarter (27.3%) of all U.S. psychiatric office visits. The relative risk of receiving these short visits was greater for patients who paid with public resources, were over 65 years of age, were nonwhite in race (brief visits only), received a prescription for an antipsychotic medication, or were diagnosed as having a psychotic disorder. CONCLUSIONS: Short office visits are provided to a particularly vulnerable patient population. The reduction in Medicare copayments for medication management services should increase the patient demand for these short visits. However, where the new Medicare schedule has lowered physician fees for these services, the financial incentive to provide short visits will decrease and patient access may become limited.

Adolescent↗
PubMed1992

Revising axis V for DSM-IV: a review of measures of social functioning.

OBJECTIVE: Axis V, which uses the Global Assessment of Functioning Scale in the multiaxial system of DSM-III-R, is under review for DSM-IV. This article examines what is known about axis V and selectively reviews the literature on measures of social functioning to identify potential alternatives to the Global Assessment of Functioning Scale. METHOD: About 25 studies on the use, reliability, and validity of axis V in DSM-III and DSM-III-R are reviewed. In addition, nearly 30 measures of social functioning are reviewed and analyzed as potential substitutes for the Global Assessment of Functioning Scale. The analysis focuses on the strengths and weaknesses of each measure for assessing functioning on axis V. RESULTS: Axis V measures are modestly reliable and valid but not widely used. The authors identify and discuss two particular limitations of the Global Assessment of Functioning Scale: 1) the combination of measures of symptoms and measures of social functioning on a single axis and 2) the exclusion of physical impairments from the rating of functioning. CONCLUSIONS: None of the measures of social functioning reviewed is clearly superior to the Global Assessment of Functioning Scale for use on axis V. A modified version of the Global Assessment of Functioning Scale, separating the measures of social and occupational functioning from the measures of symptoms and psychological functioning, is proposed for field testing, along with a new set of instructions permitting the rating of limitations due to both physical and mental impairments.

Persons with Disabilities↗
PubMed1992

Initial level of care and clinical status in a managed mental health program.

Data from 9,055 adult intakes performed over two and a half years of a managed mental health care demonstration project in a large U.S. city were used as indirect measures of quality of care. The level of care to which patients were initially assigned was examined in relation to the patients' clinical status as judged by both managed care case managers and treatment providers. During the period, assignment to inpatient care of patients in almost every clinical category decreased. The decrease seemed to reflect a policy decision to limit use of all inpatient services rather than a selective elimination of unnecessary hospitalization. Case managers rated a smaller proportion of patients severely disturbed, partial hospitalization was rarely used as an alternative to inpatient care, and detoxification services were increasingly used as an inpatient alternative. Although these data reinforce common beliefs about managed care, the quality of managed care programs can be accurately assessed only with data collected specifically for evaluation purposes.

Alcoholism↗
PubMed1991

Determining disability due to mental impairment: APA's evaluation of Social Security Administration guidelines.

OBJECTIVE: APA evaluated the Social Security Administration's (SSA's) medical standards and guidelines for determining disability due to mental impairment to determine how well the standards and guidelines operationalize the statutory definition of disability in a manner consistent with current psychiatric practice. METHOD: Seventy-two psychiatrists were trained in one of two procedures: those in the sequential evaluation condition were trained in the process and forms used by the SSA's reviewing medical consultants, and those in the statutory definition condition were trained in the statutory definition of disability and application of clinical judgment according to this standard. Decisions regarding claimant's ability or inability to work were recorded on an instrument designed for the study. Each condition consisted of 12 panels of three members. They reviewed 732 actual claims for disability benefits. The panelists reviewed claims independently, then rendered panel judgments. Each claim was reviewed by one panel in each condition. RESULTS: The proportion of agreement between conditions for panel decisions (0.77) was higher than chance agreement (kappa = 0.46). The high level of agreement on claims judged to have good medical evidence and on which confident decisions were made (proportion of agreement = 0.96, kappa = 0.78) suggests that disagreements largely reflected ambiguities in application of the standards and guidelines to more complex cases or those with inadequate information. CONCLUSIONS: The SSA's revised medical standards and guidelines reflect clinical decisions about ability to work based on the statute and, with procedural modifications, should be retained. The SSA should be involved in further systematic studies to develop a field of scientific inquiry into disability and psychiatric disorders.

Adult↗
PubMed1991

Evaluation of a Maryland fiscal incentive plan for placing state hospital patients in nursing homes.

In Maryland a six-month fiscal incentive to promote nursing homes' acceptance of chronic patients discharged from state psychiatric hospitals was evaluated after one year. During the fiscal year of the incentive program, such placements (N = 182) increased an average of 38 percent from previous years. Of 163 patients whose placements were evaluated, 22 were returned to the state hospital during the six-month period that the incentive was in place. Ten of the 22 were returned within 30 days of placement. Contrary to expectation, the return rate did not rise after the incentive was discontinued; four patients were returned during the second six months of the study period. Most returns during the first six months were due to patients' physical and verbal threats. The results supported the use of short-term fiscal incentives and emphasized the importance of intensive supportive interventions with chronic mentally ill patients early in the nursing home placement.

Aged↗
PubMed1991

The quiet success of the national plan for the chronically mentally ill.

In 1978 the President's Commission on Mental Health called for a national plan for the care of persons with chronic mental illness. The plan was completed and released in 1980, but was never adopted as the policy of the incoming Reagan Administration. Despite changes in attitudes in the 1980s toward the federal government's role in human services and an atmosphere of fiscal restraint, many of the plan's specific recommendations for changes in Supplemental Security Income, Social Security Disability Insurance, Medicaid, and Medicare have been implemented. In this paper, the implementation of these recommendations is analyzed. The authors discuss some of the strategies used by mental health advocacy groups to make gains in the 1980s. Recommendations for the 1990s are discussed.

Chronic Disease↗
PubMed1990

The Social Security Disability Evaluation Study.

Disability has continued to gain attention as a research topic in the mental health field. Both the SSA and the National Institute of Disability and Rehabilitation Research currently fund research aimed at understanding the vocational needs of severely mentally ill adults, particularly those in supportive employment programs. The National Institute of Mental Health funds research on disability and rehabilitation, particularly research on innovative approaches to increasing the individual's level of functioning and quality of life. All of these federal agencies anticipate continued funding of research on disability. This evaluation of the SSA's 1985 medical standards and guidelines by the APA is an example of the type of disability research that seeks to address issues related to individuals as well as important policy questions. In this evaluation, both the appropriateness and utility of the standards and guidelines were assessed, and the quality of disability decisions for severely mentally impaired applicants was studied.

Disability Evaluation↗
PubMed1990

Barriers to the care of persons with dual diagnoses: organizational and financing issues.

Among the frustrations of managing the dual disorders of chronic mental illness and alcohol and drug abuse is the fact that knowing what to do (by way of special programming) is insufficient to address the problem. The system problems are at least as intractable as the chronic illnesses themselves. Organizing and financing care of patients with comorbities is complicated. At issue are the ways in which we administer mental health and alcohol and drug treatment as well as finance that care. Separate administrative divisions and funding pools, while appropriate for political expediency, visibility, and administrative efficiency, have compounded the problems inherent in serving persons with multiple disabilities. Arbitrary service divisions and categorical boundaries at the State level prevent local governments and programs from organizing joint projects or creatively managing patients across service boundaries. When patients cannot adapt to the way services are organized, we risk reinforcing their overutilization of inpatient and emergency services, which are ineffective mechanisms for delivering the care these patients need. This article reviews the barriers in organization and financing of care (categoric and third party financing, including the special problem of diagnosis-related groups limitations) and proposes strategies to enhance the delivery of appropriate treatment.

Alcoholism↗
PubMed1990

Hospitalization for psychiatric illness under Medicare, 1985.

National and state-level data on Medicare-covered hospital discharges after treatment for psychiatric illness in 1985 were analyzed to determine the distribution of cases among various types of psychiatric and general hospitals. In most states, 80 to 90 percent of Medicare patients with psychiatric conditions received care in a setting that provided specialized treatment for psychiatric illness. However, the distribution of discharges among public and private psychiatric hospitals and general hospitals with psychiatric units varied substantially among states. Between 1984, the first year of Medicare's prospective payment system, and 1985, the number of discharges decreased overall, and a shift toward treatment in specialized psychiatric facilities and toward settings exempt from the prospective payment system was apparent.

Data Collection↗
PubMed1990

Design for the national evaluation of the Robert Wood Johnson Foundation Program on Chronic Mental Illness.

The Robert Wood Johnson Foundation chose the University of Maryland Mental Health Policy Studies Program to conduct an independent national evaluation of its Program on Chronic Mental Illness, a large-scale demonstration in which nine cities across the country are participating. The national evaluation aims at describing the implementation of the program and assessing its impact on clients. The evaluation effort comprises five groups of interrelated studies: a site-level study, a community care study, housing studies, financing studies, and disability and vocational rehabilitation studies. Taken together, the components of the evaluation should provide evidence that will help create new structures and processes in large cities for delivering care to persons with chronic mental illness.

Chronic Disease↗
PubMed1990

Form and function of mental health authorities at Robert Wood Johnson Foundation Program sites: preliminary observations.

The Robert Wood Johnson Foundation Program on Chronic Mental Illness provides support for broad change in the organization, financing, and delivery of services in public systems of care for chronic mentally ill persons. To address the lack of an organizational locus of responsibility in these systems, the foundation proposed that each of the nine cities participating in the program create a mental health authority that would centralize administrative, clinical, and fiscal oversight. The authors present site-by-site observations of the developing mental health authorities at the end of the program's two-and-a-half-year planning phase. They conclude that although the Robert Wood Johnson Foundation grant represented a significant incentive for innovation, at this relatively early stage in the demonstration authorities at only a few sites had achieved direct clinical responsibility for chronic mentally ill persons. Although services had expanded, no site had yet developed a comprehensive system of care that included inpatient services as well as a full range of ambulatory, housing, and social welfare services.

Ambulatory Care↗