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PubMed1990

Rehabilitation. Psychology's greatest opportunity?

Rehabilitation is one of the fastest growing areas in the health industry. Supported by several key pieces of legislation, psychologists have established themselves as integral health care providers in rehabilitation. Although psychologists have benefited from legislated membership in rehabilitation, most individual psychologists and the psychological associations have failed to recognize the importance of public policy for the practice of psychology. Escalating health care costs have resulted in major revisions in the manner in which health insurers reimburse treatment. Medicare, the major federal health insurance provider, increasingly has been viewed as a model for the provision of all health care. The historic exclusion of psychologists from Medicare has limited the scope of psychologists' practice and the growth of professional psychology. The recent inclusion of psychologists in Medicare improves but does not solve practice and policy issues confronting psychology. Knowledge of national health policy formulation and greater participation by psychologists in health policy is necessary to secure the scope of professional practice most psychologists expect.

Persons with Disabilities↗
PubMedDate not supplied

Direct reimbursement of nurse practitioners in health insurance plans of research universities.

The purpose of this study was to explore the nature of health insurance coverage research universities offer their employees and the extent to which these employers offer options providing for reimbursement of services of independent nurse practitioners. A request for health insurance documents mailed to 77 public research universities resulted in a response rate of 83 per cent. A total of 75 per cent sent usable descriptions of insurance coverage for analysis. Among the respondents, 69 per cent (n = 40) reported offering insurance through Blue Cross/Blue Shield companies. Nursing services reimbursed generally included traditional nursing care such as private duty nursing and home health care. Coverage of nursing services that overlap with traditional medical practice, such as prenatal care and labor and delivery services of nurse midwives, anesthesia services of nurse anesthetists, psychiatric services of nurse specialists, and primary care nursing services of nurse practitioners, was less evident. Findings generally indicated that in spite of the presence of enabling or mandatory state legislation for third-party reimbursement of nursing services, legislation is not being implemented in many states by employers in their purchase of group policies.

Data Collection↗
PubMed1997

The role of economic evaluation in the pricing and reimbursement of medicines.

In most countries, governments or health insurers have taken initiatives to influence the price and utilization of medicines. One stated objective of these schemes is to encourage efficiency, or cost-effectiveness. In principle, economic evaluation should to be relevant to decisions about the pricing and reimbursement of health technologies, since it offers a way of estimating the additional value to society of a new intervention (e.g. medicine) relative to current therapy. However, the application of economic evaluation in drug pricing and reimbursement schemes is variable. Therefore, this paper reviews the actual and potential role of economic evaluation in different drug pricing and reimbursement schemes, such as 'free pricing' systems (United Kingdom, United States), two-stage administered systems (France), reference pricing systems (Germany, Netherlands, Sweden) and economic evaluation systems (Australia, Canada). It is concluded that, other than in the case of Australia and Canada, the potential role of economic evaluation could be greatly developed, especially in the case of new medicines, for which there is no close substitute. Comments are also given on the practical problems of using this approach. However, it is noted that economic evaluation alone cannot set a price for a medicine, since a decision has to be made about the proportion of added value going to society and the proportion going to the pharmaceutical company as a reward for innovation.

Australia↗
PubMedDate not supplied

The 'quiet' crisis in mental health services.

The failure of insurers and managed care organizations to reimburse providers of mental health services for the costs of care has led to a crisis in access to these services. Using the situation in Massachusetts as a case example, this paper explores the impact of this defunding. Unable to sustain continued losses, hospitals are closing psychiatric units, and outpatient services are contracting or closing altogether. The situation has been compounded by the withdrawal of many practitioners from managed care networks and cuts in public-sector mental health services. Unless purchasers demand effective coverage of mental health treatment, mental health services will likely continue to wither away.

Adult↗
PubMed1992

Including an all-payer reimbursement system in a universal health insurance program.

This article examines the feasibility of including an all-payer reimbursement system in a universal health care program in the United States. An all-payer system would keep intact the current array of private and public insurers, but would require that they each pay the same price for hospital and physician services. The article concludes that an all-payer system would face far fewer political barriers than a purely government-financed system. Furthermore, it has a number of advantages over the financing schemes currently used, particularly with respect to enhancing access to care and controlling costs. But there are several potential problems: agreeing on a common payment rate; controlling the volume of services provided; devising a way of incorporating alternative delivery systems; and dealing with the issue of whether providers will be able to "balance bill". The extent to which these problems can be solved will, to a large degree, determine whether an all-payer system can live up to its promise.

Cost Control↗
PubMed1981

Drug reimbursement in four Nordic countries.

The purpose of the present study was to describe the reimbursement systems in use for the reimbursement of medicaments purchased within the state compulsory health (sickness) insurance systems in four Nordic countries, and to study whether and how reimbursement for drug consumption. During the study period drug reimbursement has been selective in Denmark and Norway, but in Finland and Sweden it had been a mixture of selective (free drugs) and unselective (partially reimbursed drugs). The use of drug reimbursement as a control measure to regulate the quality and quantity of drug consumption has not been explicit. With the exception of monetary costs, the objectives of the control have not been explicitly stated, and administrative practices have sometimes been arbitrary. Even though at first sight the Finnish, Norwegian and Swedish systems of free medications may appear alike, a more detailed analysis of diseases and drugs showed tht the comprehensiveness and contents of the schemes differed. The differences seemed largely of an administrative nature. The financial costs of drug reimbursement had risen rapidly and varied from one country to another, being highest in Sweden.

Denmark↗
PubMed1986

Reflections of a CHAMPUS-APA peer reviewer.

Peer review is a major professional response to the problems of health insurance coverage for psychiatric services. Standard insurance programs reimburse only services that are conventional and cost-effective. The system assumes that services are skillfully documented by providers. Experience as a peer reviewer helps clinicians acquire skill in documentation.

Cost-Benefit Analysis↗
PubMedDate not supplied

Funding mechanisms for depression care management: opportunities and challenges.

OBJECTIVE: Inconsistent third-party reimbursement for depression care management is a significant economic barrier to the utilization and sustainability of the chronic illness care model in primary care practice settings. We review common mechanisms used to procure payment for depression care management services, discuss obstacles encountered and suggest future directions. METHOD: We describe several extant models for funding depression care management services in use at the demonstration sites of the Robert Wood Johnson Foundation funded "Depression in Primary Care" project and similar programs. We derived this information from ongoing discussions with the sites' project directors and through an extensive electronic literature search on "care management, funding mechanisms and depression." RESULTS: Funding mechanisms include (a) practice-based care management on a fee-for-service basis, (b) practice-based care management under contract to health plans, (c) global capitation, (d) flexible infrastructure support for chronic care management, (e) health-plan-based care management, (f) third-party-based care management under contract to health plans and (g) hybrid models. CONCLUSIONS: While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms (e.g., variations in care managers' credentials and work locations and third-party payer concerns about overutilization and transaction costs), several recent policy advances provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices.

Capitation Fee↗
PubMed2002

Forces promoting health insurance coverage of homebirth: a case study in Washington State.

The movement of childbirth to the hospital in the early 1900s and the eventual establishments of health insurance reimbursement for hospital birth--but not for homebirth--solidified and reflected physician dominance in the area of obstetrics. Until recently, it was rare that a health insurer or a health maintenance organization (HMO) would cover a homebirth. However, in Washington State the majority of health insurance groups cover homebirths, which are generally attended by licensed midwives. In this context, our research is a case study focused on answering the question: What are the forces promoting the extensive coverage of homebirth by health insurers in Washington State? Data were gathered primarily through fourteen (14) in-depth, audiotaped interviews with key informants in relevant agencies and organizations in the state (i.e., state offices; midwife and other professional associations; and health insurance groups). Results suggest that consumer demand was an important precipitating factor without which changes to health insurance coverage would likely not have been made. Additionally, changes in state policies and professional mobilization on the part of licensed midwives were critical factors facilitating the widespread reimbursement for homebirth. Health care organizations' concerns for cost containment had little impact on this health insurance trend. Our study concludes that jurisdictional openings in the system of professions can be facilitated by a small number of strategically positioned individuals.

Adult↗
PubMed2002

Payer type and the returns to bypass surgery: evidence from hospital entry behavior.

In this paper, we estimate the returns associated with the provision of coronary artery bypass graft (CABG) surgery, by payer type (Medicare, HMO, etc.). Because reliable measures of prices and treatment costs are often unobserved, we seek to infer returns from hospital entry behavior. We estimate a model of patient flows for CABG patients that provides inputs for an entry model. We find that FFS provides a high return throughout the study period. Medicare, which had been generous in the early 1980s, now provides a return that is close to zero. Medicaid appears to reimburse less than average variable costs. HMOs essentially pay at average variable costs, though the return varies inversely with competition.

California↗
PubMed2006

Telepsychiatry and e-mental health services: potential for improving access to mental health care.

Reforming mental health care is a focus of many ongoing initiatives in the United States, both at the national and state levels. Access to adequate mental health care services is one of the identified problems. Telepsychiatry and e-mental health services could improve access to mental health care in rural, remote and underserved areas. The authors discuss the required technology, common applications and barriers associated with the implementation of telepsychiatry and e-mental health services.

Health Services Accessibility↗