Biomedical subjects
Publications and source records attributed to S S Sharfstein.
Major economic forces are dramatically affecting the practice of psychiatry. In the light of these changes, the author suggests how psychiatrists can have an expanded role in the emerging outcome-driven world of health care.
Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Schizophrenia affects from 0.5 percent to 1.0 percent of the population and is often a chronic relapsing illness with high morbidity. Because it strikes young adults, the lifetime direct and indirect costs are considerable. One method of budgeting the costs of treatment is through a prospective method with the development of "risk-adjusted" capitation rates that take into account a patient's past use of services, perceived health status, and level of disability. Such a system may provide opportunities to improve the quality of mental health services by increasing service flexibility, particularly in the development and differentiation of outpatient services. The essence of the approach is to encourage early intervention by reducing financial barriers for patients, especially barriers to alternatives to expensive inpatient services. One method currently employed in Rochester, New York, which creates a capitation payment system for the chronically mentally ill, will be described. The implications of this system for public policy will be discussed as we struggle to treat and care for chronic schizophrenic patients in humane and compassionate ways.
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.
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Explore the source record for details and available documents.
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.
Efforts at cost containment in medicine and psychiatry are ubiquitous. The escalating costs of health care have led to a variety of initiatives to manage the use of expensive settings and treatments. Cost containment aims to be cost efficient. When it is applied to the treatment of the severely mentally ill, clinical and ethical dilemmas intensify. Access to health insurance is more restricted for the mentally ill (Sharfstein et al. 1984). The benefits that are available are rationed by "fourth party" case managers, independent operators who make money by selling "third party" insurance companies the services of reviewing ongoing care in such a way as to contain costs and conserve resources. Most often this involves pressure to develop discharge plans and to move patients from the expensive inpatient to the less expensive outpatient setting as soon as it is safe and feasible (Melnick and Lyter 1987). For some patients, however, as illustrated below, this proves to be a most formidable task.
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In the quest for cost containment, case-managed care can harm some patients who are catastrophically ill and treatment resistant. One such case is presented and the "catch-22" situation described where the case manager determined that the chronicity and severity of the case deemed the patient "custodial" and discharge planning was ordered despite the fact that the patient had excellent continued inpatient benefits. The consequences of premature discharge or transfer to a state facility should be studied carefully as we move to more case-managed care. The process of managed care, which has become increasingly costly and time consuming, should also be scrutinized.
In 1987 Medicare benefits for the mentally ill were expanded for the first time in 22 years. A major change was the removal of limits and copayments for the "medical management of psychopharmacologic agents." Payment for medical management recognizes the trend toward the remedicalization of psychiatry; however, medical management can be defined either broadly or narrowly. The authors suggest pricing strategies for both medical management of mental disorders and psychotherapy. Enlightened design of psychiatric benefits will cover all forms of treatment according to appropriate rules. Access to treatment for mental illness is at stake as these rules develop.