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The poor standard of dressing provision in the crucial role of community nursing is discussed by Roy Lukacs, assistant district finance officer, Aylesbury and Milton Keynes Health District and Mike Dormer, product manager, patient care division, Johnson and Johnson. They ask why the drug tariff system is still common to many districts.
To improve understanding of the cost-effectiveness of a managed health care program for individuals with mental retardation, we have described financing, utilization, and outcomes of the Developmental Disabilities Center at Morristown Memorial Hospital. The costs and benefits of health care coordination, a key feature of this program, were discussed. Under this model, annual, unreimbursed costs of health care coordination in 1989 averaged $668 for people with severe mental retardation. However, the total reimbursable costs of inpatient care were reduced. In addition, medical outcome data from ongoing research projects suggest that the program has been an important vehicle for improving the health of people with mental retardation in the community. The costs, revenues, and financing of this program were presented in order to assist candidate sites in the replication of this model. The role of this type of program in health care reform was discussed.
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The main objective of this article is to examine the willingness to pay for a viable rural health insurance scheme through community participation in India, and the policy concerns it engenders. The willingness to pay for a rural health insurance scheme through community participation is estimated through a contingent valuation approach (logit model), by using the rural household survey on health from Karnataka State in India. The results show that insurance/saving schemes are popular in rural areas. In fact, people have relatively good knowledge of insurance schemes (especially life insurance) rather than saving schemes. Most of the people stated they are willing to join and pay for the proposed rural health insurance scheme. However, the probability of willingness to join was found to be greater than the probability of willingness to pay. Indeed, socio-economic factors and physical accessibility to quality health services appeared to be significant determinants of willingness to join and pay for such a scheme. The main justification for the willingness to pay for a proposed rural health insurance scheme are attributed from household survey results: (a) the existing government health care provider's services is not quality oriented; (b) is not easily accessible; and, (c) is not cost effective. The discussion suggests that policy makers in India should take serious note of the growing influence of the private sector and people's willingness to pay for organizing a rural health insurance scheme to provide quality and efficient health care in India. Policy interventions in health should not ignore private sector existence and people's willingness to pay for such a scheme and these two factors should be explicitly involved in the health management process. It is also argued that regulatory and supportive policy interventions are inevitable to promote this sector's viable and appropriate development in organizing a health insurance scheme.
A year-long field training project comprised of university faculty and graduate students as participant-conceptualizers in developing proposals for two comprehensive community mental health centers is described. Students experienced an urban setting of high psychosocial vulnerability and a complex network of social-political agencies. Their participation in all phases of the project is discussed, from gathering demographic data to negotiating contractual arrangements for services.
Kupers' comment on the cyclical nature of the recent history of mental health in the United States is important and hopeful. Another dimension of the current public mental health scene is the decrease of the federal role in the overall system. This role has been a critically important one in the recent past. Hopefully, it will be restored to its full capacity as the country strives for a balanced system of mental health care for all its citizens.
Changes in funding, clientele, and services from 1971 to 1980 were examined cross sectionally and with cohorts for two types of CMHCs that differ in their structure for providing inpatient service. Inpatient provider CMHCs grew in revenues and shifted from reliance on federal funds to revenues from services and states. Inpatient-affiliated CMHCs fell in revenues (in constant dollars) and changed little in their proportional reliance on federal dollars. Inpatient provider CMHCs averaged more additions and episodes of care than inpatient-affiliated CMHCs. Inpatient-affiliated CMHCs grew more from 1971 to 1976, but from 1976 to 1980 inpatient provider CMHCs grew, while inpatient-affiliated CMHCs dropped or grew less. The relatively poor final showing of inpatient-affiliated CMHCs parallels findings with total revenues.
What happens to community mental health centers when federal funding ends? Analysis of the funding patterns of a cohort of "graduate" community mental health centers indicates that these centers remained fiscally viable subsequent to termination of basic federal grants. However, further analysis revealed two distinct funding patterns within the cohort. One group relied primarily on increased third-party reimbursements to offset the end of basic federal grants. The other sought more state funds and additional federal grants available through the Community Mental Health Center Amendments of 1975. As more centers "graduate," federal "floor funding" may be necessary to insure the survival of some of them.
The current Alcohol, Drug Abuse, and Mental Health block grant program represents a return to the form of federal promotion of community mental health services that existed in the 50s and early 60s. Federal mental health policy during this period is outlined, and associated changes in the number and characteristics of outpatient psychiatric clinics are described. This policy is contrasted with both the CMHC program that succeeded it and the current block grant program. Differences with the earlier block grant suggest that the current one will be minimally effective in maintaining or increasing state support of community-based services.
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Within a public human service organization interaction occurs among diverse constituencies such as clients, donors, and professionals. Several recent trends affecting relationships among constituencies are identified and problems emerging from these trends are considered. Since various changes within human service organizations have occurred during the 1960s and early to mid-1970s, one may speculate about future developments which may result from these trends. It is suggested that each constituency must adapt to changing circumstances in a spirit of cooperation if the organization is to be effective.
Four methods for assessing priorities of health problems were use in a 15-county Appalachian region. Despite overall similarities the tendency is for providers to focus on categorical disease problems while consumers focus more on organization and financing problems. Only one of the methods described, community diagnosis, uses objective data; thus, the health professional must assume an educational role and help consumers use and interpret data. Prioritization of health problems allows for more appropriate use of limited resources.
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An analysis of the current roles of the federally funded community mental health center and the public mental hospital suggests that despite the rhetoric about a community mental health revolution, the mental field has yet to undergo significant change. Ideological, political, economic, and structural barriers-characteristics of the field itself-impede such change outside, inside, and across the centers and hospitals. Recent court decisions on patients' rights, however, have the potential for moving the field into a period where "bold new action" actually can occur.
Funding arrangements have a direct and substantial influential effect on the delivery of mental health services. Despite the original intent of the community mental health center philosophy, centers have not been freed from programmatic limitations imposed by the fiscal systems. The focus of this article is the inpatient unit that has the key role as relates to a center's ability to raise revenue. Using data from a study of community mental health center inpatient utilization patterns, the authors demonstrate that centers face the problem of becoming revolving doors (for a recidivist population). Existing fiscal arrangements, it is suggested, reinforce this pattern and tend to downplay innovative alternatives to traditional inpatient care.
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