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Medicare and the maintenance of treatment standards.
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The "assignment of benefits" road--no longer a one-way street.
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Psychiatric malpractice: the low frequency risks.
This article updates a long-term study of psychiatric malpractice. The American Psychiatric Association professional liability insurance programme has insured an average of 10,000 psychiatrists each year since 1984. Two thousand malpractice insurance cases have been entered into a purpose configured relational database to permit analysis of clinical, demographic and economic variables. The results to date are reported and specific low frequency risks identified. Their significance for governmental and private sector mental health professionals is discussed.
Strategic implications of healthcare reform for mental health providers.
While most of the recent national attention on healthcare reform has focused on physicians, acute-care hospitals, and the insurance industry, what about mental healthcare providers? Where do psychiatric hospitals, psychiatrists, psychologists, and other mental healthcare professionals fit into the healthcare payment system of the future? For example, if the United States ends up with what is called universal access--a payment source for all Americans--will it include mental health benefits? The stakes are high; one quarter of the American population either has no health insurance or is covered by Medicaid. Many current reform proposals include tort reform; but how would it affect mental healthcare providers? Will managed care--primarily health maintenance organizations (HMOs) and preferred provider organizations (PPOs)--be a part of the reshaping of the United States healthcare system? This article has three objectives: To summarize the various healthcare reform proposals and provide a description of the key elements anticipated in the most likely reform package. To consider the strategic implications of payment reform for the mental healthcare industry. To identify strategies for mental healthcare providers that are likely to be useful regardless of the shape of healthcare reform.
The patient-centered bibliography: uniting library services with the mission of the psychiatric hospital.
The primary function of a hospital is patient care. The development of a patient-centered bibliography is suggested as the most effective way of organizing information and insuring its use in the psychiatric hospital. The patient-centered bibliography is a collection of readings which are especially pertinent to the care of an individual patient. It consists of a core of current literature organized around the patient's multiaxial diagnosis (including psychosocial stresses), but may also include articles on psychopharmacology, special psychotherapeutic techniques, and literature on family dynamics. The collection can be expanded to include patient-centered information for two other purposes as well: milieu therapy and patient education.
Physician Health Research Conference (Estes Park, Colorado--September 15-17, 1996): progress report one year later.
The 1996 Physician Health Research Conference was the first conference to focus exclusively on research issues and methods for impaired physicians. The conference was initiated by James Shore, M.D., professor and chairman of the Department of Psychiatry in the School of Medicine at the University of Colorado Health Sciences Center and superintendent of the Colorado Psychiatric Hospital, and Stephen Dilts, M.D., Ph.D., medical director of the Colorado Physician Health Program and clinical professor of psychiatry at the University of Colorado Health Sciences Center. Forty participants represented a wide range of national organizations. The conference was supported by contributions from the American Medical Association, American Psychiatric Association, Colorado Physician Health Program, Colorado Physician Insurance Program, and the Department of Psychiatry and Colorado Psychiatric Hospital at the Health Sciences Center. In addition, the conference was cosponsored by the American Academy of Addiction Psychiatry, the American Society of Addiction Medicine, and the Federation of State Physician Health Programs. This paper summarizes the formal presentations of the conference.
Economics of practice and inpatient care.
The nature and structure of inpatient psychiatric services are rapidly evolving. This article identifies and explores how these changes are being influenced by four interrelated areas: rapid growth in general and private hospital psychiatric practice; increased connections of public, private, and voluntary sectors of care; the emergence and quick acceptance of capitated and managed care programs; and dramatic change and growth in the insurance industry. These four interrelated areas further the development of a two-tier system in psychiatry: one for those with insurance, and one of the poor and the severely disabled. The changes in these four areas have also led to greater demand for increased economic competition among services, and new alliances and innovations in the delivery of treatment. This article discusses how the four areas have combined to support a two-tier system and how they are likely to affect the future evolution of general and private hospital inpatient psychiatric practice.
Eating disorders and health insurance understanding and overcoming obstacles to treatment.
Eating disorders are complex in cause and course, with biomedical, psychiatric, and psychosocial components. To maximize the likelihood of recovery, patients require skillful and coordinated care from various health care professionals, including medical professionals, mental health professionals, and nutritionists. All too often, at some point in treatment, clinicians discover that their patients' health insurance status has been compromised or that further treatment is denied because of maximization of mental health benefits. It is important for patients, families, and health care professionals to understand the health insurance issues that are involved in the treatment of eating disorders and learn strategies that may help to overcome the obstacles that these issues present.
The SES setting of psychiatric hospitalization in Israel.
OBJECTIVES: This study examined the relationship between the SES level of localities and psychiatric hospitalization measures to determine the SES place in the planning of mental health services. METHODS: The unit of analysis in this study was the city. Data collected from Central Bureau of Statistics (CBS), the National Insurance Institute and the national psychiatric hospitalization case register were used to investigate the association of SES for each city, the number of disability pension recipients for each city and the hospitalization measures: admission rates, length of inpatient episode and the length of tenure in the community. RESULTS: The socioeconomic level of cities correlated significantly with the number of disability pension recipients in each city and the hospitalization measures: admission rates, length of inpatient episode and the length of tenure in the community. However, the relationship between the SES and both the psychiatric admission rates and the psychiatric disability rates differed between the lower and the higher parts of the SES scale: Both measures went up as the SES went up from level 1 to level 3 and went down as the SES level went up from level 4 to level 8. CONCLUSIONS: The demand for psychiatric hospitalization was higher in the poorer communities. Reaching equity in distributing community public mental health resources seems to be not only more appropriate but also more cost-effective.
Utilization and costs of psychiatric care: key issues in the coming debate on national health insurance.
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Mental health services under a U.S. national health insurance plan.
Sometime during the 1990s, the U.S. Congress could enact legislation that would establish universal access to basic hospital and physician services and, later, create a national health insurance plan. The author explores the potential effect of these programs on state psychiatric facilities; short-term acute psychiatric care facilities, including those under for-profit ownership; mental health professionals; and delivery of patient care. Each year about 63 million uninsured Americans would be eligible for basic health care under a universal access program, and mentally ill patients who are now unable to afford care would then be eligible for limited mental health services. National health insurance, enacted after the universal-access approach fails, is likely to support the current trend of proportionately more ambulatory and less inpatient mental health care. Wealthy Americans are likely to use the national health insurance system but may also use private mental health services, thereby perpetuating the current pluralistic health care delivery system.
The discriminating characteristics of for-profit versus not-for-profit freestanding psychiatric inpatient facilities.
This study examines the characteristics that discriminate between ownership types among private, freestanding psychiatric inpatient facilities in the United States. Use of data from the Inventory of Mental Health Organizations (National Institute of Mental Health 1983, 1986), revealed that not-for-profits provide more services and serve more of the underinsured, while for-profits serve the better insured, concentrate primarily on inpatient services, and serve more children, adolescents, and substance abusers. A surplus bed capacity among for-profit psychiatric hospitals is presumed to contribute to lower occupancy rates and less turnover in the for-profit sector. Not-for-profit psychiatric facilities are also found to be more involved in professional training and to be more accessible through emergency services. However, the misclassification test in the discriminant procedure reveals that a significant group of not-for-profit facilities looks more like its for-profit counterpart group than like other not-for-profits. Study findings are interpreted both in terms of debates over the tax-exempt status of not-for-profit hospitals and the potential negative service effects of proprietization.
Psychiatric nursing in the USA.
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Hospitalization for mental illness: evaluation of admission trends from 1941 to 1971.
A study of the diagnostic composition of the inpatient population of Ontario and Canadian psychiatric facilities has shown an important change in hospital-treated illness over the period 1941-71. Patients with nonpsychotic disorders accounted for 54% of all admissions to Ontario public mental hospitals in 1971, compared with only 8% in 1941. The trend was similar for both first admissions and proportion of readmissions, and was similar for psychiatric units of general hospitals. In contrast, the overall rate of first admission for psychotic disorders to inpatient facilities remained remarkably constant over time, as did the proportion of readmissions among all admissions. The findings dispel the notion that the increasing proportion of readmissions is due largely to a rapid turnover of former long-stay psychotic patients (the "revolving-door phenomenon"). The findings could not be attributed to a changing prevalence of types of psychiatric illness, increased availability of psychiatric inpatient facilities or comprehensive medical insurance.
Changing characteristics of schizophrenic patients admitted to state hospitals.
OBJECTIVE: Characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 were studied to examine changes in the demographic profile of the patient population and in principal sources of payment for hospitalization over the study period. METHODS: Information on patients' demographic characteristics and principal payment sources was obtained from a nationally representative data base compiled about every five years by the National Institute of Mental Health. RESULTS: Among schizophrenic patients admitted between 1970 and 1986, the proportion of African-American males increased. By 1986 patients were less likely to pay for care through private insurance or their own resources. They were more likely to receive Medicare and to lack medical insurance. Medicare use increased largely among white patients, and medical indigency largely among African-American patients. CONCLUSIONS: Changes in the characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 may be related to changes in nosology, in the prevalence of schizophrenia, and in the types of patients likely to be admitted to state hospitals. The increase in the number of medically indigent patients accentuates the need for more adequate finding of state hospitals.
[25th anniversary of the Institute for Psychogenic Diseases of the General Health Insurance Agency of Berlin].
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Patient ethnicity and diagnosis of emotional disorders in women.
BACKGROUND AND OBJECTIVES: Ethnic background and family resources have not been sufficiently examined in relation to emotional disorders and their treatment in primary care settings. This study examined the diagnosis and management of psychological disorders in family practice patients to explore how ethnicity may affect the diagnosis and treatment of emotional disorders. METHODS: A random sample of family practice patients was selected from 1 year of office visits. The charts of 100 African-American and 100 Caucasian women were audited for primary and secondary diagnoses, presenting symptoms, prescriptions, psychotherapy referrals, history of domestic violence and substance use, and family and demographic characteristics. Chi-square tests of association and multiple regression were used to analyze the data. RESULTS: Ethnic background was significantly associated with a diagnosis of a psychiatric disorder; 44% of Caucasian patients were diagnosed with an emotional disorder, compared with 24% of African-Americans. Proportionately more Caucasian patients with psychiatric diagnoses were treated with psychotropic medications. Patient race, marital status, and insurance status explained 15% of the variance in psychiatric diagnoses. CONCLUSIONS: Women's ethnicity is significantly associated with the diagnosis of emotional disorders and their treatment.