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PubMed2006

The business of addiction treatment: A research agenda.

The social and economic costs of addiction are substantial and of great concern to society. Research in the past decade has led to promising therapies that appear to be highly effective but not widely diffused. This leads one to wonder if there is something about the structure, dynamics, or structure and dynamics of the addiction treatment industry that is getting in the way. However, there has been very little research in the areas of organization, finance, or management practices within the substance abuse treatment field-the kinds of issues that reduce the potential impact of addiction treatment industrywide. With this as background, this article introduces the Center for Organization and Management in Addiction Treatment (COMAT) and a special section on research in the "business of addiction treatment." Many other industries have experienced significant problems that are similar, in many respects, to those seen in substance abuse treatment, but research in leadership, innovation, investment, organization, and consolidation strategies has helped to overcome those problems. COMAT is dedicated to implementing and testing evidence-based methods from other industries to improve the outcomes performance and, ultimately, the clinical effectiveness of service providers in the addiction treatment field.

Alcoholism↗
PubMed2006

The implementation of managed behavioral healthcare in Colorado and the effects on older Medicaid beneficiaries.

BACKGROUND: One of five persons over the age of 65 experiences a diagnosable form of mental illness. Yet their access to and use of specialty services are the lowest among all age groups. It is unclear how managed behavioral healthcare has affected this problematic situation. The Colorado Medicaid Mental Health Capitation Pilot Program, implemented in 1995, provided an opportunity to investigate the impact of managed behavioral healthcare on older Medicaid beneficiaries. STUDY AIMS: This study compared two capitated administrative models of Medicaid mental health service delivery to a traditional fee-for-service model, and specifically focused on how these models shaped service use and expenditure patterns for Medicaid beneficiaries over the age of 65. METHODS: This study employed a quasi-experimental, pre-post design with a non-equivalent comparison group that reflects the implementation of capitation financing in some parts of Colorado and not others. A difference in difference specification was used to identify the effects of capitation under two administrative models relative to areas remaining under fee-for-service reimbursement. Logistic and Ordinary Least Squares regression were used to estimate service use and (logged) expenditures per repeat and total number of service users. Generalized corrections for heteroskedasticity and repeated observations were applied. Probabilities and average user expenditures were derived from regression results with a fixed case-mix and compared to actuals. RESULTS: The analyses indicated that one of the capitated administrative models increased the total number of older beneficiaries who used services while the total number of service users decreased in the other capitated models. Both capitated models reduced repeat use and expenditures for specialty mental health services relative to the traditional FFS model. DISCUSSION: Capitation had the expected effect of reducing the duration and intensity of treatment. Clear differences between the two capitated administrative models emerged that appeared consistent with their management philosophies. Measured effects were limited to services covered by capitation and may have been influenced by the observational design. Overall results were somewhat different from those pertaining to younger populations studied in Colorado. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: While capitation clearly reduced total expenditures for older beneficiaries, its influence on specific treatment process measures such as user expenditures, repeat users and total users may vary considerably across treatment systems. Notably, capitation may result in increases or decreases in total users within a specific sub-population such as elders. IMPLICATIONS FOR HEALTH POLICIES: This analysis provides critical information for those state mental health and Medicaid agencies that are expanding the application of managed behavioral healthcare within a demographic environment where the population of older adults with mental illnesses is increasing. Financing, organization and their impact on specific treatment populations need to be considered in developing and applying managed behavioral health care. IMPLICATIONS FOR FURTHER RESEARCH: The differential effects on elders by administrative models needs further explication and should be measured against clinical and social outcomes as well as the effect of other sources of financing and service substitution.

Aged↗
PubMed1995

Issues in measuring and improving health care quality.

This issue of the Health Care Financing Review focuses on issues and advances in measuring and improving the quality of care, particularly for Medicare and Medicaid beneficiaries. Discussions of quality-related topics are especially timely, given the growing and widespread interest in improving quality in the organization, financing, and delivery of health care services. This article has several purposes. The first is to provide a brief description of some of the causes underlying the growth of the health care quality movement; the second is to provide a contextual framework for discussion of some of the overarching themes that emerge in this issue. These themes include examining conceptual issues, developing quality measures for specific sites and populations, and creating or adapting data sets for quality-measurement purposes.

Acquired Immunodeficiency Syndrome↗
PubMed1985

Financing urban primary health services. Balancing community and government financial responsibilities, Pikine, Senegal, 1975-81.

It is difficult to prejudge a community's capacity to satisfy its basic human needs, because no satisfactory method has been developed to predict the potential resources of a poor community. To improve their health conditions, all people, even poor, have some resources available. When they can manage themselves and be involved in decision making, they can become very efficient and contribute many material and human resources needed to organize health facilities in situations where the government fails to provide for wide-ranging needs, especially in the new cities. This was demonstrated by our experiment in Senegal between 1975 and 1981. This paper discusses the respective roles and responsibilities of the communities and the government in terms of: the process of setting up and carrying out the project in Pikine and the stages of community participation; and the pre-conditions for successful co-management in a primary care organization financed in a large part by the community.

Community Health Services↗
PubMed1995

Healthcare financing in the Kingdom of Saudi Arabia: a review of the options.

Healthcare financing in the Kingdom of Saudi Arabia is overwhelmingly public and services provided in government facilities are free. However, even through the proportion of government outlays allocated to health care has been increasing, the actual amount per capita has been decreasing; a result of the double effects of a fast-growing population and a declining government revenue. Duplication of services and frivolous demands are identified sources of waste. This paper gives a brief description of current sources of financing, reviews the options for the future, argues for measures to raise cost consciousness and assesses the impact of user charges on the low income. Closer integration and co-ordination of the government agencies and introduction of user charges as a first step toward eventual adoption of a national health insurance are the measures recommended to increase efficiency and cost-awareness as well as to raise revenue.

Delivery of Health Care↗
PubMed2006

Why do we need an oral health care policy in Canada?

Although health care is a right of citizenship, severe inequities in oral health and access to care persist. This paper provides information on the financing, organization and delivery of oral health services in Canada. It concludes that dental care has largely fallen out of consideration as health care. The increasing costs of dental insurance and disparities in oral health and access to care threaten the system"s sustainability. The legislation that allows the insured to receive tax-free care and requires all taxpayers to subsidize that expenditure is socially unjust. Unless an alternative direction is taken, dentistry will lose its relevance as a profession working for the public good and this will be followed by further erosion of public support for dental education and research. However, never before have we had the opportunity presented by high levels of oral health, the extensive resources already allocated to oral health care, plus the support of other organizations to allow us to consider what else we might do. One of the first steps would be to establish new models for the delivery of preventive measures and care that reach out to those who do not now enjoy access.

Canada↗
PubMed1981

The National Plan for the Chronically Mentally Ill: a review of financing proposals.

In this, a companion piece to the preceding article, the author summarizes and examines the financing issues and recommendations set forth in the National Plan for the Chronically Mentally Ill. The major federal programs that provide assistance to chronic patients are described briefly. Sixteen proposed incremental reforms designed to fill gaps in the existing service system are listed and discussed; nine involve changes in the Medicaid program. The author also considers the options to go beyond incremental changes toward the establishment of a comprehensive program focused specifically on the needs of the chronically mentally ill. He discusses the advantages and drawbacks of three methods of organizing financing of mental health services that are described in the National Plan--a structured services program, a benefit-voucher program, and a cash transfer program.

Chronic Disease↗
PubMed1989

A vision of long-term care. To care for tomorrow's elderly, hospitals must plan now, not react later.

In the next two decades, rapid, fundamental changes will take place in the way we finance, organize, and provide long-term care services. Because the elderly make up such a large portion of the patient population, America's hospitals should be concerned--and involved. There are six keys to the future of long-term care: a sharp increase in elderly population, a new generation of elderly, restrained government role, intergenerational strains, growing corporate concern, and the rise of "gerotechnology." These trends and countertrends will result in a new look in the long-term care landscape. By the year 2010, changes will include a true public-private financing system, provider reimbursement on the basis of capitation and prospective payment, coordinated access to services, dominant alternative delivery systems, a different breed of nursing homes, fewer staffing problems, patient-centered care, a new importance in housing, and an emphasis on prevention. For hospitals, this future vision of long-term care means that significant opportunities will open up to meet the needs of the elderly-at-risk and to achieve a competitive position in the burgeoning elderly care industry.

Aged↗
PubMed1990

[How urgent is the need to reform medical education?].

Many proposals regarding reforms of our health services pertain to the organization, financing and material and technical equipment of health departments. But many people forget that the causes of inadequate meeting of health needs of individuals and society are much more profound. The present article draws attention to the urgent need of reforms of the medical curriculum at medical faculties and postgraduate institutes. The core of the problem are rigid forms of teaching and the absolute predominance of biomedical and technological aspects of training over psychosocial and sociooecological aspects of training of future doctors. The submitted paper refers to attitudes and recommendations of WHO and other international organizations concerned with medical training.

Czechoslovakia↗
PubMed1998

Financing changes of schistosomiasis control programmes in China 1980-1995: a case study in Songzi county.

To assess the financing changes of schistosomiasis control programmes in China and estimate the impact of these changes on patients' treatment-seeking behaviour and control of schistosomiasis, a survey was conducted in five schistosomiasis-endemic areas of the lake regions, Hubei province, in 1996. This paper reports financing changes and their impact on the incidence and prevalence of schistosomiasis from one of the five areas as a case study. By examining the surveillance and financial data from 1980 to 1995, and through focus group discussions we found that the schistosomiasis control programmes in People's Republic of China have gone through dramatic financing changes from 1980 to 1995, when the transitions of China's social, economic, and political systems happened. The proportions of funding to schistosomiasis control programmes from high level governmental agencies, county budgets, and services revenue changed from 60%, 23%, and 17%, respectively, in 1980-1987 to 0.7%, 22.3%, and 72% in 1995. The percentages of expenditure of schistosomiasis control activities, salaries and bonuses, and other activities unrelated to schistosomiasis control, were 53.5%, 14.4, and 17.2% in 1980. These percentages changed to 7.7%, 33.3%, and 53.3%, respectively, in 1995. The preponderant role of the state in organizing, financing, and delivery of the services was replaced with the new system which is more influenced by the market economy. The incidence and the prevalence of schistosomiasis in the study area have increased year by year from 1980 to 1990, although there has been a tendency to decrease after 1991 but not to the low pre1980 levels. The collapse of the community-based medical system in rural areas and the dramatic financing changes of schistosomiasis control programmes have created major difficulties for schistosomiasis control in China.

China↗
PubMed2004

Prefrontal system dysfunction and credit card debt.

Credit card use often involves a disadvantageous allocation of finances because they allow for spending beyond means and buying on impulse. Accordingly they are associated with increased bankruptcy, anxiety, stress, and health problems. Mounting evidence from functional neuroimaging and clinical studies implicates prefrontal-subcortical systems in processing financial information. This study examined the relationship of credit card debt and executive functions using the Frontal System Behavior Scale (FRSBE). After removing the influences of demographic variables (age, sex, education, and income), credit card debt was associated with the Executive Dysfunction scale, but not the Apathy or Disinhibition scales. This suggests that processes of conceptualizing and organizing finances are most relevant to credit card debt, and implicates dorsolateral prefrontal dysfunction.

Adolescent↗
PubMed1976

Health care financing in China.

Today's China, still a developing country with per capita health expenditure of 50 cents to one dollar (U.S.), has established a complex network of health facilities and well-distributed health personnel through the efforts of the existing political structure. The curative health services are decentralized and provide care through a variety of plans which combine capitation prepayment and modified fee-for service. Each plan is striving for the goal of making health care accessible to all at low cost, and hence, efforts of cost containment for self-sufficiency are widely practiced. The responsibility of the preventive health services (such as health education, screening, family planning, food distribution, etc.) are assumed by the central government and they are provided without charge to encourage maximal utilization. Other features of the Chinese system discussed include self-reliance, self-sufficiency, mass orientation, regionalization and innovative utilization of existing facilities, and personnel.

Allied Health Personnel↗
PubMedDate not supplied

Health system reform under the Russian health insurance legislation.

The Russian (1993 amended) health insurance legislation initiated a far-reaching reform in the financing, organization and management of the Russian health system. However, the implementation of the legislation has been slow and unstructured due to a lack of appropriate administrative and financial mechanisms: these concern entitlement, private-public mix, financial responsibilities of government at all levels, investment instruments, reimbursement and compensation systems, and a well-defined role of government. These issues are discussed in this article in the context of the Russian economy, the state of the health system, and the reform effort in the system.

Financing, Government↗
PubMed1996

An historical perspective on the roots of managed care.

To most people, managed care and managed competition are terms of relatively recent origin, but the concepts are far from new. The use of these terms and their principal predecessors, prepaid group practice and medical care foundations, are symbolic of the underlying problems of the health care systems identified in the United States. With the passage of time, the individuals who first spoke loudly and well on the subject have come and gone, but the central theme of what they had to say was that major changes in the organization, financing, and delivery of health care are absolutely essential if high-quality preventive, diagnostic, and therapeutic care are to be available to the population at an acceptable cost. This paper reviews the early years of recognition of the need for change and the sporadic start of the changes. The presentation leaves out details on the recent growth of managed care and the political turmoil caused by the high level of medical costs, the inadequate documentation of the quality of care, and the large numbers of people who have no insurance or at best inadequate insurance.

Health Maintenance Organizations↗
PubMed1995

Why market-driven forces in our health industry might eventually stumble: what could happen then?

The Republican takeover of Capitol Hill suggests that the payer-driven forces of managed care and the regional networks will serve as the centerpieces to improve the organization, financing, and delivery of our nation's health services. The "voluntary" alliances that are now being forged may stumble when attempting to restrain the inflationary spiral of Medicare and Medicaid expenditures and when seeking to finance the care of an increasing number of uninsured working poor and their dependents. The American health industry can anticipate experiencing increasingly monopolistically competitive environments. The public will eventually demand the formation of state health services commissions to foster a semblance of control. Within this framework, the German decentralized, multipayer, multitier approach, which is self-governing and allows for negotiating reimbursement rates between insurers and providers, offers a preferred model to the traditional American public utility model.

Antitrust Laws↗
PubMed1988

A comparison of primary care systems in the USA, Denmark, Finland and Sweden: lessons for Scandinavia?

In the United States large corporately owned health care delivery institutions, some of which are known as health maintenance organizations (HMOs), are assuming an increased prominence in the provision of primary care (PC). These private organizations are similar in many ways to the public-sector providers that have functioned for decades within the Scandinavian systems. This article explores the similarities and differences between these two PC approaches. This is accomplished by contrasting the governance, organization, financing and staffing of the PC systems of three Nordic countries (Denmark, Finland, and Sweden) to that of the US. Also provided is a critical analysis of the extent to which each model attains the ideal attributes of PC including; 1) accessibility, 2) comprehensiveness, 3) coordination and continuity, and 4) sensitivity to the patient's social milieu. For each facet of PC assessed, the American models offer approaches that are worthy of consideration by Scandinavian clinicians and planners. These include innovations in the areas of coordination between primary and secondary care, preventive care for adults and incentives for financial efficiency. Also, although successful in attaining many attributes of PC, this article discusses some perceived weaknesses of the Scandinavian systems.

Continuity of Patient Care↗