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PubMed2004

The effect of parity-induced copayment reductions on adolescent utilization of substance use services.

OBJECTIVE: The purpose of this study was to determine if the reduction in copayment amount by a large self-insured state employer increased utilization of adolescent services. Specifically, the study sought to discover if the number of unique adolescent users of substance use outpatient services increased as a result of reductions in cost-sharing arrangements. METHOD: The data utilized in this study were 31,585 records from administrative claims data on utilization of mental health and substance abuse services from members of a state indemnity plan fromJuly 1998 through December 2001, translating to 36 months of pre-intervention data and 6 months of postintervention data. Monthly longitudinal data before and after benefit design change were analyzed using a quasi-experimental time series design, using Box and Jenkins' autoregressive, integrated, moving-average time-series modeling methods. The primary outcome measure was the number of unique users of services. RESULTS: The hypothesis that service utilization would increase following the implementation of a reduction in copayment amount (the intervention) was supported in these analyses for adolescents' substance use service utilization. A significant increase in the number of unique adolescent users of substance use services was detected in the month following the intervention (p < .01). CONCLUSIONS: The results of this study suggest that a reduction in adolescents' substance use service copayment requirements to a level equal to those for general medical services may be a step toward assuring full parity between such types of services. These findings provide potentially important information regarding the possible effects of broader policy changes, as parity in benefit design is a common component of laws that attempt to ensure "full parity."

Adolescent↗
PubMed2006

To retain or remove user fees?: reflections on the current debate in low- and middle-income countries.

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

Community Health Services↗
PubMedDate not supplied

Faculty practice and university hospital integration.

With a long history as unique providers of health care, academic medical centers have been exempt from many of the troubles plaguing less distinguished health care organizations. But with the increasing dominance of managed care, academic medical centers are facing fierce competition from aggressive and often better organized providers. Burdened with cumbersome and tradition-laden organization structures and volatile turf issues, many academic medical centers are still in the early stages of collaborating with physicians and other providers to develop the care continuums being demanded by payors. Few are operating as truly integrated delivery systems. As the stakes get higher, academic medical centers must accelerate development of health delivery systems by integrating faculty practice ambulatory services with university hospital patient services and those of network partners. Together these services can form the foundation of a system that ultimately provides a complete array of inpatient and outpatient services and is supportive of teaching, research and faculty and staff entrepreneurial activities.

Academic Medical Centers↗
PubMed2003

[German-speaking mental health services research - what and how is reported? An analysis of publishing in Psychiatrische Praxis 1999-2002].

OBJECTIVE: In mental health service research, the investigated services and care systems as well as the research methodology should be described in a precise and transparent fashion so that findings can be clearly interpreted and used. Therefore, this study investigates what is reported in German language publications on mental health service research. METHOD: All original papers on mental health service research, that were published in the Psychiatrische Praxis between 1999 and 2002, were systematically reviewed and, using a structured classification system, subjected to content analysis. In particular, it was assessed what forms of care had been studied and what characteristics of care were reported. RESULTS: 54 % (199) of all original publications reported mental health service research in a wide sense. Of these, 8 % were qualitative studies. 58 % of studies investigated in-patient treatment, 20 % comprehensive care systems, and 4 % services provided by psychiatrists or psychotherapists in private office practice. There were hardly any studies on innovative service models. In 51 % of studies, authors had conducted investigations within their own service or care system. In most articles characteristics of the patient sample were exactly described, whilst precise information on the researched service, such as funding, staffing and organisation, was usually missing. DISCUSSION: There still is relatively little research on outpatient services, and mental health service research is not yet appropriately based in the community. Requirements for exact and comprehensive descriptions of the researched services' and care systems are rarely met. In general, the findings suggest that mental health service research in German speaking countries might benefit from studies with researchers who are independent from the investigated service, the evaluation of innovative service models, and above all a standardised description of the services and context in research studies.

Germany↗
PubMed1988

Are referrals by general practitioners influenced by the availability of consultants?

To investigate variations in the number of outpatients seen in different NHS regions of Great Britain data on numbers of outpatients, number of consultants per 100,000 population, mortality, and prescribing rates were analysed for four specialties: medicine, thoracic medicine, psychiatry, and dermatology. The number of outpatients seen was strongly associated with the provision of consultants in all four specialties and only weakly associated with need for outpatient services as measured by standardised mortality ratios and mean numbers of prescriptions per patient issued by general practitioners. Interpretations of differences in referral rates need to take into account variations in the supply of specialists as a factor that may influence the referral behaviour of general practitioners.

Catchment Area, Health↗
PubMed2004

Managed care and mental health: personal realities.

A review of the literature revealed mixed reviews on the impact of managed care on mental health service delivery. Research supports that managed care contributes to a reduction in inpatient costs and an increase in outpatient service use. Other studies suggest that there are problems with access and quality of care. An additional issue is whether or not, and to what extent, mental health services are "carved out" from physical health for patients. This study discusses the findings of a qualitative analysis of Medicaid managed care recipients on the barriers and enabling factors to obtaining mental health services in a full carve-out managed care model. Results indicate that reduced access, quality of care problems, and a lack of integration of care exist. Additionally, recipients' interactions with managed care, service providers, and caseworkers affect their mental health care. The results also report on the tactics used by recipients to cope with service problems. Implications for social work practice and research are discussed and recommendations for service delivery and evidence-based education are delineated.

Case Management↗
PubMed2006

Integration between general practice and mental health services in Italy: guidelines for consultation-liaison services implementation.

PURPOSE: This paper illustrates some guidelines for the implementation of Consultation-liaison services in contexts where GPs work alone. We present some activity data of our experience in the period 1999-2004 and a critical evaluation of what works and what does not work. CONTEXT: In Italy single-sited spontaneous initiatives of co-operation and integration between general practice and psychiatry have been implemented in many regions. Recently, the Italian Health Care Government has begun to encourage integration between primary and secondary care for the management of mental health. The Bologna Consultation-liaison Service opened in 1999 in one area. The service was first located in the Community Mental Health Centre and subsequently in a medical non-psychiatric outpatient service. In 2002, the services were implemented in the overall city area, and the Bologna Consultation-liaison Service had its own office in the centre of the town. DATA SOURCE: Data have been collected by reviewing clinical charts. They include clinical (mental status examination, progress notes) and socio-demographic data, assessment scales that measure psychological distress and disability, reports for GPs, and consultation outcome. CONCLUSION: A consultation-liaison service like the one proposed in this paper could contribute to an efficient and fully-integrated collaborative management of common psychiatric disorders, reducing the use of mental health services.

Journal Article↗
PubMed2005

Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2006 payment rates. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. In addition, the final rule with comment period describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. This final rule with comment period also changes the requirement for physician oversight of mid-level practitioners in critical access hospitals (CAHs). In this final rule with comment period, we also are responding to public comments received on the November 15, 2004, final rule with comment period pertaining to the ambulatory payment classification (APC) group assignment of Healthcare Common Procedure Coding System (HCPCS) codes identified in Addendum B of that rule with the new interim (NI) comment indicator. These changes are applicable to services furnished on or after January 1, 2006.

Ambulatory Care↗
PubMed1985

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model.

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)

Criminal Law↗
PubMedDate not supplied

Data capture for quality management nursing opportunity.

It is predicted that by the year 2000, with or without national health care reform, outpatient services may account for nearly half of a hospital's net revenues. As greater emphasis is placed on outpatient care it is imperative that data collection tools be developed that will not only evaluate the quality of care but also include data to measure administrative interests. The Hines VA, in conjunction with the Minneapolis VA, adapted a simple, computerized information collection system known as PANDAS. This article discusses the various technologies available for data collection; the criteria used in the selection of discrete optical mark reading technology; the development of an out-patient database for ambulatory care encounters; and the opportunities that exist for extracting data to examine and trend nursing activities, and developing outcome criteria for patient care.

Ambulatory Care↗
PubMed1996

The Langton Centre: a home detoxification model.

The Langton Centre is a public hospital located in Darlinghurst within the South Eastern Sydney Area Health Service. It specialises in the treatment of addiction and it provides a comprehensive range of both inpatient and outpatient services to a diverse population. The Centre has a reputation of excellence in looking for market gaps in the drug and alcohol field and filling these with innovative quality programmes. The gap the Langton Centre is presently filling is home detoxification.

Adolescent↗
PubMed2006

[Inpatient post-transplant services and intermittent rehabilitation in patients after kidney transplantation].

Late graft outcome depends on an intensive post-transplant care program. Direct post-transplant inpatient rehabilitation in a specialized hospital as well as outpatient services, along with an inpatient check-up every 2-3 years are important for maintaining an excellent long-term graft function. In our experience recognizing and treating risk factors after organ transplantation such as arterial hypertension, vasculopathy, hyperlipidemia, metabolic syndrome including PTDM, osteoporosis, recurrent diseases and also the recipient's education (compliance) are most important landmarks in a post-transplant care program. This inpatient as well as outpatient post-transplant care program with the aim of long-term graft function for organ recipients, performed in a network, represents a modern health service including effective and economical aspects, which health insurance in Germany is obliged to pay for.

Germany↗
PubMed1994

Ethnicity and the use of outpatient mental health services in a national insured population.

OBJECTIVES: Factors affecting ethnic differences in the use of outpatient mental health services are analyzed in an insured, nonpoor population to determine if lower use by Blacks and Hispanics persists when socioeconomic and other factors are controlled. METHODS: To identify significant predictors of the probability and amount of use, insurance claims data for a population of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed with the Andersen and Newman model of health service utilization. Logistic and ordinary least squares regression models were estimated for each ethnic group. RESULTS: Blacks and Hispanics had lower probabilities and amounts of use when compared with Whites after controlling for a number of variables. CONCLUSIONS: Since ethnic differences in the use of outpatient mental health services exist even in an insured, nonpoor population, factors other than lower socioeconomic status or insurance coverage--for example, cultural or attitudinal factors and service system barriers--are likely responsible. Such findings have policy implications in the current climate of health care reform to increase access to care for the underserved.

Adolescent↗
PubMedDate not supplied

Private medical services in acute-care hospitals in Israel.

The objective of this study was to assess the proposed introduction of out-of-pocket funded inpatient and outpatient services (abbreviated as PMS) into government acute-care hospitals in Israel. This issue of public-private mix in not-for-profit hospitals is discussed in terms of the experience with PMS gained in selected advanced market economies. Then, the major contours of the Israeli system of health care, and the gradual evolving of patient-financed medical services within government acute-care hospitals in Israel, is described. The experience gained in the few public hospitals in Jerusalem that have been operating PMS is assessed critically. The concluding part reviews the advantages and disadvantages of these developments in public and government acute-care hospitals in Israel. It is concluded that PMS in public hospitals in Israel represents a policy aimed primarily at benefiting a select group of senior physicians in those hospitals.

Financing, Personal↗
PubMed2005

Insect venom hypersensitivity: experience in a clinical immunology/allergy service in Singapore.

INTRODUCTION: To study the profile of patients with allergy to the venom of insect stings. METHODS: 31 consecutive cases referred to our clinical immunology/allergy outpatient service from June 1, 1998 to June 30, 2002 were reviewed. RESULTS: These patients comprised 3.5 percent of 889 cases referred during the study period. Their mean age was 28.8 +/- 10.5 (range 19-57) years and the majority were males (90.3 percent). Of these, 20 (64.5 percent) were Chinese, four (12.9 percent) were Malays and seven (22.6 percent) were of other races. 19 patients (61.3 percent) were men from the uniformed services including 12 (63.2 percent) full-time National Servicemen. 71 percent (22 patients) were stung for the first time. Urticaria (22 cases, 71.0 percent), dyspnoea (13, 41.9 percent), angioedema (12, 38.7 percent) and syncope (ten, 32.3 percent) were the most common manifestations of insect allergy. Anaphylaxis occurred in 22 (71.0 percent) cases, constituting 30.1 percent of all cases of anaphylaxis referred to our service during the study period. Although the causative insect was identified as honeybee (12, 38.7 percent), ant (four, 12.9 percent), wasp (three, 9.7 percent), and fire ant (two, 6.5 percent) by the majority of patients, ten (32.2 percent) patients were unable to identify the causative insect. The two patients stung by fire ants were Americans working in Singapore who had been stung while in the United States. Among those with anaphylaxis, honeybee, wasp and fire ant venom, for which specific immunotherapy is available, were identified as the cause in 40.9 percent, 4.5 percent, and 4.5 percent, respectively. CONCLUSION: Insect venom hypersensitivity made up 3.5 percent of allergy/immunology referrals and 32.8 percent of cases of anaphylaxis referred to our institution. The majority were military servicemen who developed allergic reactions during the course of duty. The inability to identify the causative insect in 50 percent with sting anaphylaxis limits the role of specific immunotherapy in our patients.

Adult↗
PubMed1990

[Rehabilitation in a community psychiatric service facility--success and failure during a one year period].

Rehabilitation outcome was examined within a social psychiatric model institution including several partial hospitalization programmes and various outpatient services. After a one-year period the treatment success was measured by objective criteria in 166 consecutively admitted patients, most of them diagnosed as schizophrenics. 75% showed improvements in terms of reduced institutional protection and a more independent living situation. Vocational rehabilitation was successful in 47%. There was no significant correlation between these outcome measures. A poor outcome was found in a group of patients who had received a comparatively high rate of therapeutic activities and was classified by sociodemographic variables. Consequences concerning the therapeutic approach in community mental health services and its evaluation are shown.

Adult↗
PubMed1979

I. An operational study in the outpatient department of Machakos Hospital (1968).

The demand for outpatient services at Government Hospitals in Kenya increased considerably during the period 1962-1967. As a result a discrepancy developed between demand for services and the resources to meet these demands. An operational study, dealing with medical, technical and administrative aspects, was carried out at the outpatient department at Machakos Hospital in 1968. The study comprised: the arrival pattern of patients, work measurement of the activities of the medical assistant, diagnosis, prescriptions, the distribution of patients over the therapeutic units, waiting times and length of queues. Following the study recommendations, expected to improve the efficiency of the clinic and the service to the patients, were put forward to the Ministry of Health. The most important recommendations dealt with: the need for overall leadership; direction of traffic; the position and the role of the medical assistant; the organization procedures, in particular at the medical assistants' units and at the injection room and pharmacy. The present study does not include: the attitude of the staff; expectation and satisfaction of patients; the quality of care provided; the cost of service.

Appointments and Schedules↗