A comparison of public and privatized approaches to managed behavioral health care for persons with serious mental illness.

This article compares public and privatized approaches to managed behavioral health care for persons with serious mental illness in Massachusetts. Data from the Department of Mental Health (DMH) for 247 patients receiving care managed by DMH and 312 in a Medicaid carve-out were compared. Repeated measures multivariate analysis of variance models were used to examine adjusted changes in number of admissions, bed days, and facilities used from a baseline year before program implementation in 1992 through two follow-up years.

Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use.

Objective: This study assessed the extent to which patients treated with electroconvulsive therapy (ECT) had diagnoses for which ECT is an efficacious treatment according to evidence-based standards.

Methods: ECT use among all beneficiaries of a large New England insurance company in 1994 and 1995 was examined using a retrospective cohort design. Associations between provider characteristics and ECT use for diagnoses outside the standards were determined using logistic regression analysis.

Characteristics of psychiatrists who perform ECT.

Objective: Use of ECT is highly variable, and previous study has linked its availability to the geographic concentration of psychiatrists. However, less than 8% of all U.S.

The influence of psychiatric disorders on patients' ratings of satisfaction with health care.

Objectives: Patient ratings of satisfaction with health care have been used by patients, insurers, and employers seeking data to compare the quality of health plans and systems of care. Concerns with these ratings include their subjective nature and potential for being influenced by patient characteristics unrelated to the quality of their care. The authors examined the influence of an active psychiatric disorder on patient satisfaction with health care, hypothesizing that patients with psychiatric disorders would be less satisfied with their health care, due to the adverse effects of these conditions on mood and cognition.

Use of electroconvulsive therapy in the Medicare population between 1987 and 1992.

Objective: Use of electroconvulsive therapy (ECT) in the Medicare population was examined to document trends and variations in the rate of use, expenditures, and patterns of treatment.

Methods: Medicare part B enrollment and claims data were used for a 5 percent nationally representative sample of Medicare beneficiaries for calendar years 1987 through 1992. Descriptive and multivariate analyses were performed.

The determinants of dumping: a national study of economically motivated transfers involving mental health care.

Objective: To examine the prevalence and determinants of economically motivated transfers (aka "dumping") from hospitals treating mental illness.

Data Sources: A composite data set constructed from three national random-sampled surveys conducted in 1988 and 1989: (1) of hospitals providing mental health care, (2) of community mental health centers, and (3) of psychiatrists.

Study Design: The study uses reports from administrators of community mental health centers (CMHCs) to assess the extent of patient dumping by hospitals.

Competition, ownership, and access to hospital services. Evidence from psychiatric hospitals.

Objectives: This article examines the impact of increasing competition among hospitals on access to inpatient services and preexisting differences in access between nonprofit and for-profit facilities. It tests theoretical propositions that suggest that nonprofit and for-profit hospitals will respond in different ways and to differing degrees to changing competitive pressures.

Methods: Drawing data from a 1987-88 national survey of psychiatric hospitals, the authors measured access in terms of the availability of different types of services and the provision of uncompensated care.

Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy.

Objective: The increasing involvement of insurers and hospitals in monitoring patient care is encroaching on the psychiatrist's autonomy in making clinical decisions. This study examined the prevalence of constraints on psychiatric inpatient practices, as well as how characteristics of psychiatrists affect the type and the degree of these external pressures.

Method: About 2,500 psychiatrists with active hospital affiliations were surveyed by mail, as a subset of APA's 1988 national survey of psychiatrists.

Variation in ECT use in the United States.

Objective: The authors measured the variation in ECT utilization rates across 317 metropolitan statistical areas of the United States and determined to what degree this variation is associated with health care system characteristics, demographic factors, and the stringency of state regulation of ECT.

Method: Data from APA's 1988-1989 Professional Activities Survey were used to estimate ECT utilization rates for the metropolitan statistical areas. Multiple regression analysis was used to determine the relative influence of provider, demographic, and regulatory factors on variation in ECT use across areas.

Schizophrenia and the life cycle.

We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the person's lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes.

Thoracic discography. A safe and reliable technique.

Objectives: To evaluate the safety and reliability of discography used to investigate thoracic disc degeneration observed on magnetic resonance (MR) imaging studies in patients with clinical pain, we analyzed retrospectively the results of thoracic discograms performed on 100 outpatients.

Methods: After MR imaging, clinically suspect, morphologically abnormal thoracic discs and at least one, nearby, control level were injected with either nonionic contrast or saline, filmed, and individually described by the patient as concordant versus nonconcordant relative to clinical pain and rated in intensity on a scale of 0-10.

Results: There were no serious complications in the series, and the authors resolved whether the injected discs related to pain in each case.

A national study of transitional hospital services in mental health.

Objectives: Shifts in care for the seriously mentally ill from inpatient to community-based treatment have highlighted the importance of transitional care. Our objectives were to document the kinds and quantity of transitional services provided by psychiatric hospitals nationally and to assess the impact of hospital type (psychiatric vs general), ownership (public vs private), case mix, and revenue source on provision of these services.

Methods: A national sample of nonfederal inpatient mental health facilities (n = 915) was surveyed in 1988, and data were analyzed by using multiple regression.

Managing competition in public and private mental health agencies: implications for services and policy.

There were clear differences in our study between the management strategies employed by public agencies and those favored by private agencies. These differences, however, appeared to reflect the realities of financing rather than any fundamental differences in their orientation toward public service. There was no clear evidence that particular management practices affected an agency's performance on measures of financial access or acceptance of referrals from public hospitals.

The case for a services-based approach to payment for mental illness under national health care reform.

In this position paper drafted by the committee on psychopathology of the Group for the Advancement of Psychiatry, the authors discuss merits and disadvantages of three different approaches to equitable coverage of mental illness: coverage for selected psychiatric diagnoses, coverage based on severity of impairment, and coverage of services. They believe that coverage of selected disorders has political appeal but is discriminatory and arbitrary; it is also impractical because clinicians may overdiagnose conditions covered by insurance and underdiagnose excluded conditions. Coverage based on severity of impairment, or disability, has similar limitations.