Showing papers in "Health Affairs in 1995"
TL;DR: The results show somewhat higher rates of mental health service use than has been reported previously, while continuing to show a substantial amount of unmet need, even among children with both a psychiatric diagnosis and functional impairment.
Abstract: This DataWatch explores the roles of human service sectors (mental health, education, health, child welfare, and juvenile justice) in providing mental health services for children. The data are from the first wave of the Great Smoky Mountains Study of Youth, a population-based study of psychopathology and mental health service use among children. The results show somewhat higher rates of mental health service use than has been reported previously, while continuing to show a substantial amount of unmet need, even among children with both a psychiatric diagnosis and functional impairment. The findings point to a significant role for the education sector, suggesting that schools may function as the de facto mental health system for children and adolescents.
1,105 citations
TL;DR: Over a one-year period, expenditures were reduced by 22 percent below predicted levels without managed care, without any overall reduction in access or relative quality, and the applicability of such a program to high-risk populations is supported.
Abstract: Massachusetts was the first state to introduce a statewide specialty mental health managed care plan for its Medicaid program. This study assesses the impact of this program on expenditur...
212 citations
TL;DR: The Commonwealth Fund's 1994 survey of 3,000 adults in fee-for-service and managed care organizations documents enrollees' experiences with choosing a plan and satisfaction with that plan.
Abstract: Prologue: Despite the failure of government to act on comprehensive health system reform, the US, health care system is undergoing rapid and profound changes. Managed care plans continue to gain a foothold throughout the country. The security of many Americans' health care rises and falls with the fortunes of the U.S. economy, both here and abroad, because health care coverage is inextricably linked to employment status. Public programs such as Medicare and Medicaid are under unprecedented scrutiny by lawmakers intent on balancing the federal budget by sharply reducing their growth rates. Amid these changes, it is critical for health policymakers to know how Americans perceive their health care system and their coverage. The survey reported in this paper is an attempt to fill the information gap. Conducted by The Commonwealth Fund in 1994, the managed care survey examines the experiences with managed care by families who have employer health coverage in Boston, Los Angeles, and Miami. Karen Davis is presi...
203 citations
TL;DR: Findings on Americans' ability to obtain health care suggest that income is highly correlated with unmet need, and most persons reporting access problems are not poor.
Abstract: This DataWatch presents findings on Americans' ability to obtain health care. Data from the 1994 National Access to Care Survey sponsored by The Robert Wood Johnson Foundation suggest that earlier studies have underestimated the access problems facing Americans by not asking about supplementary services such as prescription drugs, eyeglasses, dental care, and mental health care or counseling. Using this more inclusive definition of health care needs, we estimate that 16.1 percent of Americans were unable to obtain at least one service they believed they needed. While income is highly correlated with unmet need, most persons reporting access problems are not poor.
148 citations
TL;DR: Payers should consider using a "soft" capitation contract in which only some of the claims' risk is transferred to the managed behavioral health care company, and not allow choice by enrollees among risk contractors.
Abstract: Prologue: The term risk contracting has become a familiar part of the vocabulary and the landscape of managed care. Risk contracting refers to an arrangement whereby the cost or claims risk for an ...
134 citations
TL;DR: Two accounts of the experience with MSAs in Singapore differ over how successful Singapore has been at controlling health spending using MSAs, which reflects a divide in the broader debate over the outcomes by which MSAs should be evaluated.
Abstract: In the Spring 1995 issue of Health Affairs Mark Pauly and John Goodman outlined their proposal for medical savings accounts (MSAs) supplemented with tax credits to purchase insurance and encourage
106 citations
TL;DR: The forces shaping managed behavioral health care in the public sector are examined and strategies for managing care, such as contracting, utilization review, and monitoring are described.
Abstract: Prologue: Much of the mental health services provided in this country have come from the states, whose historical responsibility has been to care for the most disabled persons with the greatest need. In a sense, the state mental health authorities (SMHAs) have been an island around which swirled the turbulent waters of a managed care-driven marketplace. More states have been led by economic necessity and legislative mandate to embrace managed care to meet the needs of the vulnerable populations that depend on them. Now SMHAs find themselves needing the tools that private vendors of managed mental health services have perfected over the past decade, such as management information systems, incentive contracts, and fee negotiation. States have valuable experience working in an environment of limited resources and rigid bureaucracies, but they lack these tools of managed care. This has prevented them from moving to a higher level of cost containment and efficiency building. Because they entered the managed ca...
101 citations
TL;DR: The results indicate that more generous fees are associated with a greater likelihood of having a doctor's office as a usual source of care and a higher number of preventive visits at office-based sites of care.
Abstract: This study examines the effects of physician fees on children's use of preventive and illness-related ambulatory physician services under the Medicaid program. Using data from the 1987 National Medical Expenditure Survey (NMES), we examine the effects of Medicaid fee generosity on physician service use and overall ambulatory physician spending. The results indicate that more generous fees are associated with a greater likelihood of having a doctor's office as a usual source of care and a higher number of preventive visits at office-based sites of care. Having a doctor's office as a usual source of care is associated with lower overall ambulatory physician expenditures.
77 citations
TL;DR: A fundamental shift is occurring in responsibility for insuring the nation's children--from the private sector to the public sector, according to data from the Current Population Survey.
Abstract: This DataWatch examines trends in health insurance coverage of children using recent data from the Current Population Survey. The results indicate that the number and proportion of children who were uninsured changed little between 1988 and 1992. However, substantial changes occurred in the composition of the insured population: The proportion of children covered by employer-based private insurance declined from 60.7 percent in 1988 to 56.2 percent in 1992, while the proportion of children covered by Medicaid increased from 15.6 percent to 21.6 percent over the same period. These results indicate that a fundamental shift is occurring in responsibility for insuring the nation's children—from the private sector to the public sector.
77 citations
TL;DR: The failure to pass health system reform legislation in the 103d Congress taught the nation and its leaders several lessons that the nation does not yet have a system in place that works for everyone.
Abstract: Prologue: The failure to pass health system reform legislation in the 103d Congress taught the nation and its leaders several lessons. One of the clearest of these was that the nation does not yet ...
74 citations
TL;DR: This document proposes converting Medicare from a "service reimbursement" system to a "premium support" system, which would encompass not just the "public" Medicare program but also the "real" Medicare, which includes the supplemental plans to which most Medicare beneficiaries have access.
Abstract: Medicare costs are rising faster than projected revenues. Action to close the emerging deficit is inescapable. We propose converting Medicare from a "service reimbursement" system to a "premium support" system. These changes would resemble many that are now reshaping private employer-based insurance. Our reform would encompass not just the "public" Medicare program but also the "real" Medicare, which includes the supplemental plans to which most Medicare beneficiaries have access. Approved plans would have to offer stipulated services. We review numerous technical issues in moving to a new system that cannot be solved quickly and that preclude quick budget savings.
TL;DR: The different moral concerns about managed mental health care are examined and marked to mark which problems have been addressed or are in need of resolution and which problems are unique to managedmental health care.
Abstract: Prologue: Managed care in mental healthy as in general healthy is neither as good nor as evil as its advocates or detractors want us to believe. Critics, on the one hand, contend that managed care,...
TL;DR: The results of the analysis suggest that the UPMHP reduced admissions for inpatient mental health treatment, inpatientmental health expenditures, and total mental health expenditures for Medicaid beneficiaries from July 1991 to June 1992.
Abstract: This DataWatch analyzes the effect of the Utah Prepaid Mental Health Plan (UPMHP) on use of mental health services by and mental health treatment expenditures for Medicaid beneficiaries f...
TL;DR: The history of the term medical necessity is summarized and its evolution from an insurance concept controlled by practicing physicians to a rationing tool used by insurance administrators is summarized.
Abstract: Prologue: For more than thirty years public and private health insurance plans have used the term medical necessity as a placeholder to define the limits of their benefit coverage, despite widespread disagreement about its meaning. Initially, medical necessity was used to ensure that providers were paid for services performed. Now, Linda Bergthold argues, it is used primarily as a tool to control the use of scarce resources. Medical necessity has assumed greater importance, particularly because of the growth in managed care and integrated health systems and the development of expensive new technology and treatments. Because this term is undefined and thus open to interpretation, its use as the basis of coverage decisions can result in costly litigation to resolve disputes among providers, payers, and patients. Several questions must be addressed: What criteria must a treatment, service, or supply meet to be covered by insurance? Who should make these decisions? Finally, how should conflicts be resolved? I...
TL;DR: "Quality of life" encompasses functional status, access to resources and opportunities, and sense of well-being, and offers a useful perspective on the value of health care, especially for chronically disabling conditions, including chronic mental illness.
Abstract: Prologue: One of the most troubling aspects of managed care, be it for mental or physical ailments, is the degree to which the outcomes of care can be assessed. Many hours of research and many mill...
TL;DR: Features of clinical departments in teaching hospitals that are using physician assistants (PAs) and nurse practitioners (NPs) to perform some tasks previously done by medical or surgical residents imply that some of the services lost in house-staff reductions called for in many physician workforce reform proposals could be provided by alternative health professionals.
Abstract: This study documents features of clinical departments in teaching hospitals that are using physician assistants (PAs) and nurse practitioners (NPs) to perform some tasks previously done b...
TL;DR: The operational characteristics of MSAs in Singapore are outlined and the issues to be considered in any attempt to replicate such a program in the United States are highlighted.
Abstract: Medical savings accounts (MSAs) may, by introducing personal responsibility into individual decision making, reduce overall health care costs.’ This has attracted policymakers’ attention in the United States and in other countries. In fact, a mandatory MSA program has financed personal health care expenditures in the Republic of Singapore since 1984. Here we outline the operational characteristics of MSAs in Singapore and highlight the issues to be considered in any attempt to replicate such a program in the United States.
TL;DR: A 1994 opinion survey again shows Americans less satisfied with their health care system than Canadians and (West) Germans are with theirs, and important cultural differences between the countries were identified.
Abstract: A 1994 opinion survey again shows Americans less satisfied with their health care system than Canadians and (West) Germans are with theirs. Americans also report more problems in paying f...
TL;DR: Within a twelve-month period public support for the Clinton plan fell from 71 percent to 43 percent and the administration lost substantial support among two politically important groups--the elderly and Democrats.
Abstract: Prologue: Nearly a year has passed since Congress declared the demise of health care reform, at least for the current legislative session However, the problems that drove the 1993-1994 health refo
TL;DR: This report contrasts the behavior of four size classes of small businesses (fewer than fifty workers) with that of all other businesses, and examines offer rates by business size and characteristics of employers and workers in business offering and not offering insurance.
Abstract: This DataWatch reports key findings from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey, through which more than 20,000 employers in ten states were interviewed. Our report contrasts the behavior of four size classes of small businesses (fewer than fifty workers) with that of all other businesses. We examine offer rates by business size; characteristics of employers and workers in businesses offering and not offering insurance; premiums, benefits, and medical underwriting; the extent of choice among plans; and self-insurance. We discuss the implications of our findings for health policy.
TL;DR: Theda Skocpol argues that the political reversal of the November 1994 elections might turn out to be one of the biggest turning points in twentieth-century American history and that, far from being a mere casualty, the Clinton plan and Congress's failure to adopt it contributed materially to the revolt of the electorate.
Abstract: Prologue: The great health reform debate of 1994 ended with a whimper, on the heels of an election that turned out the powerful Democratic majority in the House and Senate and sent some of its most influential members packing. What role did health care reform play in this turning of political fortunes? Was it the unwitting victim? Or was it, in fact, the catalyst? In this paper Theda Skocpol argues that the political reversal of the November 1994 elections might turn out to be one of the biggest turning points in twentieth-century American history and that, far from being a mere casualty, the Clinton plan and Congress's failure to adopt it (or anything else) contributed materially to the revolt of the electorate. This is ironic, Skocpol notes, because the Clinton plan was itself designed as a middle-of-the-road compromise between the market-based and the regulation-based reforms that had been discussed up to that point. The demise of the Clinton plan is notable, she writes, not just as an attempted policy...
TL;DR: Dividing all factors determining the 1960-1993 growth in real per capita medical spending into two major categories, it is found that 70 percent of this growth resulted from cost-increasing advances in medical services induced by insurance coverage levels and spending for noncommercial medical research.
Abstract: About half the growth in real per capita medical spending from 1960 to 1993 and two-thirds of its growth from 1983 to 1993 resulted from either the level or the growth of insurance coverage, chiefly the former. Dividing all factors determining the 1960–1993 growth in real per capita medical spending into two major categories, we find that 70 percent of this growth resulted from cost-increasing advances in medical services induced by insurance coverage levels and spending for noncommercial medical research. Only 30 percent was attributable to standard factors: growth in insurance coverage, changes in age/sex mix, and growth in real per capita disposable income.
TL;DR: The Section 1115 waiver authority provides states considerable flexibility to restructure their Medicaid programs to offer health care to new populations and thus has great potential for covering large segments of the uninsured population, but there are many obstacles states must overcome both in implementing and in maintaining an 1115 program.
Abstract: Prologue: Medicaid, the federal/state program of health insurance for the poor and disabled, accounted for 20 percent of states' spending in 1994, according to the National Governors' Association. ...
TL;DR: The Federal Employees Health Benefits Program is a good model for Medicare reform and has been highly successful at holding down costs while offering a wide range of benefits and types of plans.
Abstract: The deficiencies of the Medicare program are rooted in its defined-benefit structure and in its use of price controls. Medicare should be transformed into a defined cash contribution made to beneficiaries' private plans or to the traditional Medicare program. The Federal Employees Health Benefits Program (FEHBP) is essentially such a system and is a good model for Medicare reform. The FEHBP has been highly successful at holding down costs while offering a wide range of benefits and types of plans. Its features for consumer information and plan standards also would be useful in a reformed Medicare program.
TL;DR: It is estimated that had hospitals not been subjected to increasing price competition from growth of managed care plans and financial tightening in public programs, they would have provided 36 percent more uncompensated care than was actually provided in 1989.
Abstract: This DataWatch examines the impact of hospital competition, the Medicare prospective payment system (PPS), and Medi-Cal selective contracting on the provision of uncompensated care by private hospitals in California during 1980-1989. It finds that hospitals subject to more intense competition and greater fiscal pressure from Medicare and Medi-Cal reduced their provision of uncompensated care relative to hospitals facing less pressure from these sources. We estimate that had hospitals not been subjected to increasing price competition from growth of managed care plans and financial tightening in public programs, they would have provided 36 percent more uncompensated care than was actually provided in 1989.
TL;DR: Findings on the effects of various payment strategies, managed care, and primary care gatekeepers on the outcomes and costs for the treatment of mental health conditions are summarized and the policy implications for achieving value of care, lower costs, and good health outcomes are synthesized.
Abstract: Prologue: Psychologist Martin Seligman has referred to depression as “the common cold of mental illness.” The incidence of depression has continued to climb, ranking it among the leading causes of chronic illness among Americans. As such, depression was one of five “tracer conditions' that were part of the Medical Outcomes Study (MOS), conducted longitudinally over four years beginning in 1986. The authors of this paper were investigators in the MOS; here they use their findings as a test case to discuss the effects of various payment strategies and managed care on the treatment of mental health conditions. The paper places their clinical findings in a policy context. The authors found that the cost-effectiveness of care can be improved, although this does not necessarily mean that treatment costs are lowered. In fact, often the opposite is true. “Much dis-cussion about [mental health care coverage] reflects an implicit hope that higher-quality care is the magic bullet that miraculously lowers health care...
TL;DR: This analysis reveals that the relative stability of the uninsurance rate for the entire nonelderly population belies more significant changes in insurance coverage--and lack of coverage--among various groups.
Abstract: Data from the Current Population Survey are used in this DataWatch to explore the changing composition of health insurance coverage of the U.S. nonelderly population. The authors analyze ...
TL;DR: The authors discuss the adequacy of the future physician workforce to provide services required by a health care system dominated by managed care in 2000 and 2020.
Abstract: Prologue: For several years analysts of U.S. physician supply have predicted a coming surplus of physicians by the end of this century. Several trends in the health care marketplace have exacerbate...
TL;DR: The recent experience with national health care reform offers a case study in cost estimation for mental health and substance abuse coverage and draws lessons for estimating future costs of policy initiatives.
Abstract: Prologue: States increasingly are looking for ways to improve the financing of mental health care for their disadvantaged citizens. Will the uncertainty of the cost estimating process lead them to ...