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A contract between APA and OCHAMPUS has committed APA to developing a national peer review capability for the review of out-patient psychological services. This paper describes the review criteria which apply to personality assessment and psychological testing.
In 1973 the federal government moved to limit drug reimbursement to providers in federally sponsored or supported programs, to the lowest cost at which the drug is generally and consistently available unless a difference in therapeutic effect can be demonstrated between the brand name and generic drug. This paper examines the political evolution and rationale for this program and explores the issues surrounding the ongoing controversy regarding publicly financed programs offering drug benefits. The authors speculate that the government's first attempt to control prices of pharmaceuticals, prior to enactment of some form of national health insurance, if successful, will call forth pharmaceutical industry strategies which could negate program benefits.
Public systems for physician reimbursement aim to reconcile two disparate objectives: ensuring availability of services to the poor and aged; and keeping rates of cost increase within acceptable limits. Several interesting--and unorthodox--policy simulations of physician pricing behavior are investigated through econometric estimation. Current arrangement for paying physicians are fraught with difficulties. The objectives of Medicare and Medicaid are not well served.
Although Medicare is a national program, administration of Part B payments to physicians is in the hands of insurance organizations in ten Medicare regions. The carriers follow varying practices in using actual charges within localities as the basis for determining reasonable charges for physicians' services. While some of these practices have already been shown to influence fee levels, reasonable charge determination involves many more whose influence has not been systematically studied. This paper reviews preliminary findings from a study which examines carrier differences in discretionary practices as to specialties, localities and other claims data that may be merged or compared with Medicare data in determining customary and prevailing prices used to set limits on Medicare payments, and other practices reported in an official questionnaire to carriers. The effect on fee levels and other measures of program performance is being studied after taking into account social, economic and health resource variables extracted from the Area Resource File, that are expected to influence local medical prices through the demand for and supply of physicians' services. Dependent variables representing fees are the 50th percentile of the distribution of weighted customary charges of individual physicians in an area and Supplementary Medical Insurance expenditure per enrollee. The preliminary findings in this paper concern discretionary practices, socioeconomic variables and fee distributions.
Third-party payment has profound effects on such areas of psychiatry as confidentiality; diagnosis; the therapeutic relationship; psychiatry's identification with the rest of medicine and the role of nonphysician mental health professionals; psychiatric education; and the availability, type, location, and quality control of treatment. As third-party payment becomes increasingly frequent, psychiatrists will have to come to terms with its good and bad effects in hospitals and community mental health centers as well as in private practice.
The authors examine the utilization of mental illness benefits under the Blue Cross/Blue Shield and Aetna plans for federal employees; the latter plan sharply cut back its mental illness benefits in 1975. In 1973 mental illness benefits represented 7.4% of all payments under the Blues plan and 12% under the Aetna plan. The benefit for mental illness treatment under the Blues averaged $12.52 per person covered and was 7.3% of the total benefits for all conditions. Younger enrollees and their spouses tended to receive mental illness benefits primarily for outpatient treatment and children and older adults for hospitalization. These data raise key questions for claims review and peer review activities.
This article describes a fee-for-service charging system for social work services in a "private" hospital. This system was developed because the financial pressures of the day appear to be causing a trend to decrease the level of social services provided in hospitals. The system has provided the Department of Clinical Social Work the opportunity to demonstrate the marketability of social work and to assure the department's financial viability.
Use of out-of-plan services in 1972 by Medicare members of the Health Insurance Plan of Greater New York (HIP) is examined in terms of the demographic and enrollment characteristics of out-of-plan users, types of services received outside the plan, and the relationship of out-of-plan to in-plan use. Users of services outside the plan tended to be more seriously ill and more frequently hospitalized than those receiving all of their services within the plan. The costs to the SSA of providing medical care to HIP enrollees are compared with analogous costs for non-HIP beneficiaries, and the implications for the organization and financing of health services for the aged are discussed.
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