Biomedical subjects
William Wagner
Publications and source records attributed to William Wagner.
Medicaid managed care for mental health services in a rural state.
State governments throughout the country increasingly have turned to managed care for their Medicaid programs, including mental health services. We used ethnographic methods and a review of legal documents and state monitoring data to examine the impact of Medicaid reform on mental health services in New Mexico, a rural state. New Mexico implemented Medicaid managed care for both physical and mental health services in 1997. The reform led to administrative burdens, payment problems, and stress and high turnover among providers. Restrictions on inpatient and residential treatment exacerbated access problems for Medicaid recipients. These facts indicate that in rural, medically underserved states, the advantages of managed care for cost control, access, and quality assurance may be diminished. Responding to the crisis in mental health services, the federal government terminated New Mexico's program but later reversed its decision after political changes at the national level. This contradictory response suggests that the federal government's oversight role warrants careful scrutiny by advocacy groups at the local and state levels.
Osmotic stress regulates the anticoagulant efficiency of dermatan sulfate.
Glycosaminoglycans (GAGs) in pericellular and interstitial spaces help to maintain local water homeostasis and blood coagulation balance. This study explored whether dehydrating microenvironment conditions influence dermatan sulfate's (DS) anticoagulant activity. Water transfer during antithrombin activation by dermatan sulfate was measured using osmotic stress techniques. Anticoagulant activity was determined from the change in the rate of coagulation factor Xa (fXa) inhibition. Osmotic stress accelerated reaction rates, indicating water transfer from reactants to bulk. The net volume transferred, measured using osmotic probes similar in size to the reacting proteins, was approximately 2500 mol of water per mole of fXa inhibited. The reaction efficiency, V(sat)/K 1/2 (rate at saturation/concentration resulting in half-maximal rates), determined in titrations with monosulfated dermatan sulfate and disulfated dermatan sulfate (DDS), were 4x10(4) and 2x10(5) M-1 s-1 under osmotic stress and in the presence of calcium, corresponding to 34- and 81-fold increases over efficiency measured under standard conditions. These results indicate that dermatan sulfate can contribute significantly to antithrombin activation, and that in dehydrating environments and depending of ionic conditions, its anticoagulant efficiency can exceed that of heparan sulfate (HS).
Safety-net institutions buffer the impact of Medicaid managed care: a multi-method assessment in a rural state.
OBJECTIVES: This project used a long-term, multi-method approach to study the impact of Medicaid managed care. METHODS: Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. RESULTS: After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21). There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safety-net institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. CONCLUSIONS: In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured.