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Labor market conditions and employment of the mentally ill 劳动力市场条件与精神病患者的就业
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-09-10 DOI: 10.1002/(SICI)1099-176X(199906)2:2<51::AID-MHP44>3.0.CO;2-%23
Ralph Catalano, Robert E. Drake, Deborah R. Becker, Robin E. Clark

Background

The mental health services literature includes assertions that workers with mental illness are at earlier risk of unemployment than other workers when the economy contracts. This possibility is important for several reasons. One is that such a phenomenon would support the argument that the lives of mentally ill persons are made unnecessarily stressful by the stigma of mental illness. Another is that the phenomenon could distort comparisons of the effectiveness of programs designed to prepare persons with severe mental illness for work. Despite its importance, the assertion that severely mentally ill workers are at early risk of unemployment has never been empirically tested.

Aims of the Study

We aim to test the hypothesis that unemployment among persons with severe mental illness (SMI) increases before job loss among other workers.

Methods

We test the hypothesis by applying Granger causality methods to time-series data collected in two communities in the United States (i.e., Concord and Manchester, NH) over 131 weeks beginning on 12 May 1991.

Results

We find no relationship between job loss in the labor market and the likelihood that persons with SMI will be unemployed.

Discussion

We speculate that persons with SMI participate in the secondary labor market and that their employment status is unlikely to be well described by data gathered in the primary labor market. This implies that widely available measures of labor market status, which are designed to describe the primary labor market, cannot be used to improve the evaluation of programs intended to prepare the mentally ill for work. We also discuss the possibility that persons with SMI may have needs that are better met by the secondary than by the primary labor market.

Conclusions

The intuition that workers with severe mental illness are affected earlier than other workers by labor market contraction may not be correct. We infer that persons with severe mental illness may participate in the secondary labor market about which we know relatively little. We cannot, therefore, easily adjust program evaluations to disentangle intervention effects from those, if any, of the labor market. Copyright © 1999 John Wiley & Sons, Ltd.

背景心理健康服务文献包括这样的断言:当经济收缩时,患有精神疾病的工人比其他工人更早面临失业风险。这种可能性之所以重要,有几个原因。一种是,这种现象将支持这样一种论点,即精神病患者的生活因精神疾病的耻辱而变得不必要的压力。另一个原因是,这种现象可能会扭曲旨在为严重精神疾病患者做好工作准备的项目的有效性比较。尽管这很重要,但严重精神病工人处于失业早期风险的说法从未经过实证检验。研究目的我们旨在检验严重精神疾病患者的失业率在其他工人失业之前增加的假设。方法我们将Granger因果关系方法应用于从1991年5月12日开始在美国两个社区(即康科德和曼彻斯特,NH)收集的131周的时间序列数据,以检验这一假设。结果我们发现劳动力市场中的失业与SMI患者失业的可能性之间没有关系。讨论我们推测,SMI患者参与二级劳动力市场,他们的就业状况不太可能通过一级劳动力市场收集的数据得到很好的描述。这意味着,旨在描述初级劳动力市场的广泛可用的劳动力市场状况指标,不能用于改善对旨在为精神病患者做好工作准备的计划的评估。我们还讨论了SMI患者的需求可能由二级劳动力市场比一级劳动力市场更好地满足的可能性。结论认为患有严重精神疾病的工人比其他工人更早受到劳动力市场收缩影响的直觉可能是不正确的。我们推断,患有严重精神疾病的人可能会参与我们所知相对较少的二级劳动力市场。因此,我们不能轻易地调整项目评估,将干预效果与劳动力市场的干预效果(如果有的话)区分开来。版权所有©1999 John Wiley&;有限公司。
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引用次数: 0
Information needs for community practice: responding to the challenge 社区实践的信息需求:应对挑战
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-09-10 DOI: 10.1002/(SICI)1099-176X(199906)2:2<87::AID-MHP45>3.0.CO;2-I
Grayson S. Norquist
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引用次数: 2
Managed behavioral health care and supply-side economics. 1998 Carl Taube Lecture 管理行为医疗保健和供应方经济。1998年Carl Taube讲座
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<21::AID-MHP33>3.0.CO;2-O
Richard M. Scheffler
<div> <section> <h3> Background</h3> <p>Within the past decade, the mental health care system in the United States has undergone a significant transformation in terms of delivery, financing and work force configuration. Contracting between managed care organizations (MCOs) and providers has become increasingly prevalent, paralleling the trend in health care in general. These managed care carve-outs in behavioral health depend on networks of providers who agree to capitated rates or discounted fees for service for those patients covered by the carve-out contracts. Moreover, the carve-outs use a broader array of mental health providers than is typically found in traditional indemnity plans, encourage time-limited versus long-term treatments and favor providers who are engaged in outpatient care.</p> <p>This phenomenal growth in managed behavioral health care over the past decade includes the rapid growth and quick consolidation of mental health MCOs. The period 1992–1998 shows steady and substantial annual increases in the number of enrollees in mental health MCOs, the figure more than doubling from 78.1 million people in 1992 to a projected 156.6 million in 1998, or 70% of insured lives. Moreover, these vast numbers of enrollees are becoming increasingly consolidated into a smaller number of firms. In 1997, 12 companies controlled nearly 85% of the managed behavioral health care market, with 60% of the market held by the three largest firms.</p> </section> <section> <h3> Study Aims</h3> <p>This article reviews empirical data and draws policy implications from the literature on managed behavioral health care in the United States. Starting with spending and spending trend estimates that show the average annual growth rate of mental health expenditures to be lower than that of health care expenditures in general over the past decade, the author examines utilization and price factors that may account for managed-care-induced cost reductions in behavioral health care, with special attention to hospital use patterns, fee discounting and the supply and earnings patterns of various types of mental health provider. In addition, data on staffing ratios and provider mixes of health maintenance organizations and mental health MCOs are reviewed as they reveal at least part of the dynamics of reconfiguration of the mental health work force in this era of managed care.</p> </section> <section> <h3> Conclusions</h3> <p>As measured by changes in utilization and price, widespread application of ‘classic’ managed care techniques such as preadmission review (gatekeeping), concurrent review, case management, standardized clinical guidelines and protocols, volume purchase of services and fee discou
背景在过去的十年里,美国的精神卫生保健系统在提供、融资和劳动力配置方面发生了重大转变。管理护理组织(MCO)和提供者之间的合同越来越普遍,与医疗保健的总体趋势相平行。行为健康领域的这些管理式护理分拆取决于提供者网络,这些提供者同意为分拆合同所涵盖的患者提供按人头计算的服务费或折扣费。此外,与传统的赔偿计划相比,这些例外使用了更广泛的心理健康提供者,鼓励有时间限制的治疗与长期治疗,并有利于从事门诊护理的提供者。在过去十年中,有管理的行为健康护理的显著增长包括心理健康MCO的快速增长和快速巩固。1992年至1998年期间,心理健康MCO的注册人数每年都在稳步大幅增长,从1992年的7810万人增加到1998年的预计1.566亿人,即70%的投保人,这一数字翻了一番多。此外,这些庞大的注册者正越来越多地合并为数量较少的公司。1997年,12家公司控制了近85%的管理行为医疗市场,其中60%的市场由三大公司持有。研究目的本文回顾了美国管理行为医疗的实证数据,并从文献中得出了政策启示。从支出和支出趋势估计开始,该估计显示在过去十年中,心理健康支出的年均增长率低于医疗保健支出的平均年增长率,费用折扣以及各种类型的心理健康提供者的供应和收入模式。此外,还对健康维护组织和心理健康MCO的人员配置比率和提供者组合的数据进行了审查,因为它们至少揭示了在这个有管理的护理时代,心理健康工作队伍重组的部分动态。结论通过利用率和价格的变化来衡量,“经典”管理护理技术的广泛应用,如任务前审查(把关)、并发审查、病例管理、标准化临床指南和方案,大量购买服务和费用折扣似乎大大降低了不耐烦和门诊心理健康服务提供者的成本。然而,在风险转移、不断变化的财务激励和竞争强度等复杂的市场变量中,并不是所有支出的减少或放缓都可以清楚而纯粹地归因于有管理的护理。关于正在进行的心理健康工作队伍重组的数据的含义更为明确:由于所有类型的心理健康提供者供过于求,管理式护理有很大的潜力增加提供者替代的发生率,并刺激综合团体实践的发展。对进一步研究的启示心理健康经济学的现有实证和政策文献提出了几个值得关注的领域。管理护理对心理健康护理支出年增长率的影响是暂时的,还是表明行为健康护理和一般健康护理之间的增长率存在持久差异?除了行业规模缩小之外,心理健康提供者中正在进行和将要进行的替代品是什么,以产生具有成本效益的做法?提供者和MCO之间有哪些新的财务或风险分担安排,可以提供适当和高质量的心理健康服务?版权所有©1999 John Wiley&;有限公司。
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引用次数: 13
Incorporating economic analysis in evidence-based guidelines for mental health: the profile approach 将经济分析纳入循证心理健康指南:概况法
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<13::AID-MHP34>3.0.CO;2-M
James Mason, Martin Eccles, Nick Freemantle, Michael Drummond
<div> <section> <h3> Background</h3> <p>Many western health systems are currently developing the role of clinical guidelines to promote effective and efficient health care. However, introducing economic data into guideline methodology designed to assess the effectiveness of interventions raises some methodological issues. These include providing valid and generalizable cost estimates, the weight placed upon cost ‘evidence’ and presenting cost-effectiveness information in a way that is helpful to clinicians.</p> </section> <section> <h3> Aim of the Study</h3> <p>To explore a framework for including economic concepts in the development of a series of primary care guidelines, two of which address mental health conditions.</p> </section> <section> <h3> Methods</h3> <p>A profile approach, setting out best available evidence about the attributes of treatment choices (effectiveness, tolerability, safety, health service delivery, quality of life, resource use and cost), was used to help clinicians to derive treatment recommendations in a manner consistent with both the clinical decision-making process and social objectives.</p> </section> <section> <h3> Results</h3> <p>Clinicians involved in guideline development responded well to the process. Although there was often considerable debate about the meaning and importance of different aspects of evidence about treatment, in none of the guideline groups was there failure to agree treatment recommendations.</p> </section> <section> <h3> Discussion</h3> <p>The profile approach may be particularly useful in the field of mental health where disease processes may often feature very disparate effects, over long periods of time and impacting upon a broad circle of relatives, carers and agencies in addition to the patients themselves.</p> </section> <section> <h3> Conclusion</h3> <p>A method has been applied in a series of primary care guidelines, which appears to enable clinicians to consider the issue of resource use alongside the various clinical attributes associated with treatment decisions. The basis of this work is the belief that guidance presenting physical measures describing effectiveness, adverse events, safety, compliance and quality of life, alongside resource consequences, is most likely to appropriately inform doctor–patient interactions.</p> </section> <section> <h3> Implications for Health Care Provision and Use</h3> <p>This research
背景许多西方卫生系统目前正在制定临床指南的作用,以促进有效和高效的医疗保健。然而,在旨在评估干预措施有效性的指导方法中引入经济数据会引发一些方法问题。其中包括提供有效和可推广的成本估计,对成本“证据”的重视,以及以有助于临床医生的方式提供成本效益信息。本研究的目的是探索一个框架,将经济概念纳入一系列初级保健指南的制定中,其中两项涉及心理健康状况。方法采用概况法,列出有关治疗选择属性(有效性、耐受性、安全性、卫生服务提供、生活质量、资源使用和成本)的最佳可用证据,用于帮助临床医生以符合临床决策过程和社会目标的方式得出治疗建议。结果参与指南制定的临床医生对该过程反应良好。尽管关于治疗证据的不同方面的含义和重要性经常存在相当大的争论,但没有一个指导小组未能就治疗建议达成一致。讨论简介方法在心理健康领域可能特别有用,因为在心理健康方面,疾病过程往往会在很长一段时间内产生非常不同的影响,并影响到除患者本身之外的广泛亲属、护理人员和机构。结论一种方法已应用于一系列初级保健指南中,这似乎使临床医生能够考虑资源使用问题以及与治疗决策相关的各种临床特征。这项工作的基础是相信,提供描述有效性、不良事件、安全性、依从性和生活质量的物理措施的指导,以及资源后果,最有可能为医患互动提供适当的信息。对医疗保健提供和使用的影响这项研究可能为其他群体提供一个有用的平台,让他们考虑如何将成本效益概念引入指南制定群体。指导方针是否会改变临床行为仍然是一个研究问题,也是即将进行的试验的主题。卫生政策制定的意义重要的是,政府机构要意识到,制定指导方针是一种卫生政策工具,具有制定有效指导方针的规定方法。出于控制成本或其他政治原因而试图篡改该方法可能会使改善医疗保健科学基础的有用机制名誉扫地。对进一步研究的影响完成的工作有很多局限性:例如,它以初级保健为重点,并解决了定义相当狭窄的条件。目前正在努力将范围扩大到更广泛的疾病领域和二级护理。版权所有©1999 John Wiley&;有限公司。
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引用次数: 11
Methods for the economic evaluation of health care programmes, second edition. By Michael F. Drummond, Bernie O’Brien, Greg L. Stoddart, George W. Torrance. Oxford: Oxford University Press, 1997. 卫生保健方案的经济评价方法,第二版。作者:迈克尔·F·德拉蒙德、伯尼·奥布莱恩、格雷格·L·斯托达特、乔治·W·托伦斯。牛津:牛津大学出版社,1997年。
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<43::AID-MHP36>3.0.CO;2-7
William S. Cartwright
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引用次数: 106
Providing services to families of persons with schizophrenia: present and future 为精神分裂症患者家属提供服务:现在和未来
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<3::AID-MHP31>3.0.CO;2-0
Lisa Dixon
<div> <section> <h3> Background</h3> <p>The important role of families and other caregivers in the lives of adults with schizophrenia is well documented. Persons with schizophrenia frequently live with their families of origin, and the vast majority have regular family contact. Families of persons with schizophrenia have also been demonstrated to have significant needs. Families most frequently cite the need for education and support in helping them to cope with their family member’s illness. Further, numerous studies have documented the benefits of interventions designed to meet the needs of family members.</p> </section> <section> <h3> Aims of the Study</h3> <p>This paper identifies critical issues and challenges in the provision of services to families of persons with schizophrenia and other serious and persistent mental illnesses.</p> </section> <section> <h3> Methods</h3> <p>This study draws from both a literature review and a summary of pertinent data from the Schizophrenia Patient Outcomes Research Team (PORT).</p> </section> <section> <h3> Results</h3> <p>Recent best practices standards and treatment recommendations specify that families should be given education and support. One of the PORT treatment recommendations states that ‘Patients who have on-going contact with their families should be offered a family psychosocial intervention which spans at least nine months and which provides combinations of: Education about the illness; Family support; Crisis intervention; and, Problem solving skills training’. The PORT treatment recommendations are based on well designed and rigorous research on family psychoeducation programs that demonstrate reduced relapse rates and improved patient and family well-being for persons whose families receive psychoeducation. While family psychoeducation programs have been the subject of extensive treatment trials, family members and family organizations have endorsed a variety of other models of services such as family education and consultation models. These models have not been as rigorously researched as family psychoeducation. Control groups are generally lacking. No consistent findings have been reported, although isolated studies have found increased knowledge, self-efficacy and greater satisfaction with treatment among families who have participated in family education programs. Remarkably little is known about the extent to which families actually receive appropriate services. However, PORT data from administrative claims and client interviews suggest that family services are minimal. Further, previous research has consistently revealed that families have high levels of dissa
背景家庭和其他照顾者在患有精神分裂症的成年人生活中的重要作用是有充分记录的。精神分裂症患者经常与其原籍家庭住在一起,绝大多数人都有定期的家庭联系。精神分裂症患者的家庭也被证明有重大需求。家庭经常提到需要教育和支持来帮助他们应对家人的疾病。此外,许多研究记录了旨在满足家庭成员需求的干预措施的好处。研究目的本文确定了向精神分裂症和其他严重和持续性精神疾病患者家属提供服务的关键问题和挑战。方法本研究引用了精神分裂症患者结果研究小组(PORT)的文献综述和相关数据摘要。结果最近的最佳做法标准和治疗建议规定,家庭应得到教育和支持。PORT的一项治疗建议指出,“应为与其家人有持续接触的患者提供为期至少九个月的家庭心理社会干预,该干预包括:疾病教育;家庭支持;危机干预;以及问题解决技能培训。PORT治疗建议基于对家庭心理教育计划的精心设计和严格研究,这些研究表明,家庭接受心理教育的人的复发率降低,患者和家庭幸福感改善。虽然家庭心理教育项目一直是广泛治疗试验的主题,但家庭成员和家庭组织已经认可了各种其他服务模式,如家庭教育和咨询模式。这些模式还没有像家庭心理教育那样得到严格的研究。对照组普遍缺乏。尽管孤立的研究发现,在参加家庭教育项目的家庭中,知识、自我效能和对治疗的满意度都有所提高,但尚未报告一致的发现。值得注意的是,人们对家庭实际获得适当服务的程度知之甚少。然而,来自行政索赔和客户访谈的PORT数据表明,家庭服务很少。此外,先前的研究一直表明,家庭对心理健康服务的不满程度很高。讨论如果家庭心理教育是有效的,为什么所有数据都表明它几乎没有提供?即使是家庭教育项目的使用也很有限,因为这些项目可能更容易提供,也更便宜。这些问题的一些答案可以在对传播家庭教育和心理教育模式的评估中找到。精神分裂症PORT赞助了William McFarlane的多家庭心理教育小组的传播。执行工作的一个障碍是各机构缺乏方案领导。另一个是家庭模式的哲学和原则与典型的代理实践之间的冲突。MFPG模式的推广工作正在伊利诺伊州和缅因州进行。对进一步研究的影响为了在为患有严重和持续性脑疾病(如精神分裂症)的家庭和人员提供服务方面取得进展,需要四个主要研究领域。(i) 我们需要更好地了解当前的情况,包括系统地探索不同类型的家庭正在接受或没有接受什么样的服务,以及从谁那里获得服务。对接受治疗的人群进行研究是不够的。单独的账单记录不会考虑非正式的临床医生/家庭联系人,这些联系人是有价值的。这项研究必须包括患者、家庭和临床医生的观点,并结合系统因素,如资金和服务组织。二第二个研究领域应侧重于家庭干预。什么对谁有效,成本是多少?成功的家庭模式的关键要素是什么?同伴主导的社区家庭教育项目研究严重不足。虽然心理教育已经确立了疗效,但它可能对初犯患者具有最大价值。 如何最大限度地提高家庭和临床医生对心理教育的可接受性?有没有办法利用临床医生运营和家庭运营的最佳模型来创建混合模型?家庭心理教育是将成本转移到家庭还是从家庭转移?三如何有效传播成功的家庭服务模式?尽管仍有必要更多地了解家庭服务的现状,但很明显,研究得最好的心理教育项目在典型社区的普及率有限。将临床医生和家庭成员的基层参与以及高级管理人员和付款人的努力相结合的方法可能会取得最大的成功。四需要对家庭和其他照顾者在康复和病程中的作用进行更多的研究。这项研究必须以对生物心理社会模式的理解为驱动力,并且是实证的,而不是意识形态的。这种方法将以最佳方式保护家庭免受其自身的自责倾向,以及工业化国家普遍存在的寻找指责、过错和病理的医疗模式的倾向。版权所有©1999 John Wiley&amp;有限公司。
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引用次数: 78
Abstracts translations 摘要翻译
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<46::AID-MHP39>3.0.CO;2-W
Dr Ella Rytik

See PDF file for the abstracts translations in Russian.

见PDF文件的摘要翻译俄文。
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引用次数: 0
State-of-the-art challenges for mental health services research 心理健康服务研究面临的最新挑战
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<9::AID-MHP32>3.0.CO;2-S
Susan M. Essock

Background

Research-based, state-of-the-art services for people with serious mental disorders would consist of demonstrably effective treatments, organized synergistically, and financed in ways that create incentives to provide such treatment. While research exists in these domains of treatment, organization and financing, this research base contains significant gaps, and what is known frequently neither informs policy making nor enters practice.

Review

The NIMH services-research portfolio has identified successful patient-level and system-level interventions for people with serious mental disorders, but much of this research has yet to make its way into practice. Similarly, while we have made progress in asking ‘what is good care?’, we have much less information about the answers to ‘what constitutes an adequate try?’. Writing a prescription for an efficacious medication does not constitute an adequate trial of that medication. Similarly, offering people boring psychosocial rehabilitation programs does not constitute an adequate try of promoting recovery via rehabilitation services, but what does? Defining what constitutes an adequate try can be a way of allocating scarce resources or it can be a polite way of defining when a system gets to give up on someone. As state governments move to contract with managed care entities for services for Medicaid beneficiaries, one of the great contracting challenges is defining and monitoring the provision of what constitutes an adequate try.

Discussion

To obtain better value for our health care expenditures, we need to find ways to get what we know works into practice, whether we are contracting for services or deciding which clinical therapies to pursue. For example, problem-oriented family therapy has been shown to improve clinical outcomes for people with schizophrenia, yet such interventions are rare in practice. We also need to pay more attention to the quality of the clinical care actually being delivered—not what was prescribed, nor what the clinician was trained in, nor what the job description was, but what actually is occurring. Figuring out how to contract for and disseminate efficacious treatments so that they occur and are effective in real-world settings is critically important yet is a largely unexplored area of services research. We need to answer both ‘what is good care?’ and ‘how do we get it to happen?’. Copyright © 1999 John Wiley & Sons, Ltd.

背景为严重精神障碍患者提供基于研究的最先进服务将包括明显有效的治疗,协同组织,并以激励提供此类治疗的方式提供资金。虽然在治疗、组织和融资等领域都有研究,但这一研究基础存在重大差距,而且众所周知的情况往往既没有为政策制定提供信息,也没有进入实践。综述NIMH服务研究组合已经为患有严重精神障碍的人确定了成功的患者级和系统级干预措施,但这项研究的大部分尚未付诸实践。同样,尽管我们在询问“什么是好的护理?”方面取得了进展,关于“什么是充分尝试?”的答案,我们的信息要少得多。开具有效药物的处方并不构成对该药物的充分试验。同样,为人们提供无聊的心理社会康复计划并不能充分尝试通过康复服务促进康复,但什么是呢?定义什么是充分尝试可以是分配稀缺资源的一种方式,也可以是定义系统何时放弃某人的一种礼貌方式。随着各州政府开始与管理型护理实体签订合同,为医疗补助受益人提供服务,签订合同的最大挑战之一是定义和监督什么是充分尝试。讨论为了使我们的医疗保健支出获得更好的价值,我们需要找到方法,将我们所知道的有效方法付诸实践,无论我们是签订服务合同还是决定采用哪种临床疗法。例如,以问题为导向的家庭治疗已被证明可以改善精神分裂症患者的临床结果,但这种干预措施在实践中很少见。我们还需要更多地关注实际提供的临床护理的质量——不是处方,也不是临床医生接受过什么培训,也不是工作描述,而是实际发生了什么。弄清楚如何签约和传播有效的治疗方法,使其在现实世界中发生并有效,这一点至关重要,但这在很大程度上是一个尚未探索的服务研究领域。我们需要回答“什么是好的护理?”以及“我们如何实现这一目标?”。版权所有©1999 John Wiley&;有限公司。
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引用次数: 5
Economic aspects of mental health carve-outs 心理健康例外的经济方面
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-08 DOI: 10.1002/(SICI)1099-176X(199903)2:1<29::AID-MHP35>3.0.CO;2-A
Ingo Vogelsang
<div> <section> <h3> Background</h3> <p>Recent empirical research has found behavioral health carve-outs in the US to reduce costs immediately and considerably, compared to indemnity insurance and HMOs. Carve-outs have quickly captured a large part of the organized market in US behavioral health. At the same time, market concentration has increased significantly.</p> </section> <section> <h3> Methods</h3> <p>The current paper uses concepts and results from the industrial organization and transaction cost literature to explain (i) why carve-outs hold cost advantages over other institutional arrangements, (ii) why these hold in particular for behavioral health and (iii) why this did not happen earlier.</p> </section> <section> <h3> Results</h3> <p>The main explanatory variables relate to economies of scale, the avoidance of diseconomies of scope, and the avoidance of personal relationships. The sometimes surprising lack of explicit risk-taking by carve-outs and of explicit cost-reducing incentives in carve-out contracts are more than overcome by incentives created from gaining large contracts. The specific advantages of carve-outs in behavioral health derive from a combination of lack of economies of scope with other health services, lack of economies of scale in provision of behavioral health and presence of economies of scale in management. It is conjectured that behavioral health carve-outs have benefited from biomedical innovations that changed the direction of treatments, from computerization that enables large-scale standardized management and from financial pressures on the behavioral health sector.</p> </section> <section> <h3> Discussion</h3> <p>The empirical basis for the current study is a number of case studies and the rapid penetration of mental health carve-outs in the US. Cost reductions caused by such carve-outs appear to be quite robust. Explaining cost reductions from institutional changes has to start with the question of why the old institution did not implement the same or similar changes. We have emphasized reasons why such changes were not feasible under indemnity insurance and HMOs. Nevertheless, we have not been able to evaluate quality changes that might have accompanied those cost reductions.</p> </section> <section> <h3> Implications for Health Policy</h3> <p>While further cost reductions may follow a logistic curve, which simply flattens out, there are developments, regulatory and legal in particular, that could lead to a regression of carve-out costs towards those under other institutional arrangements. Thus, the
背景最近的实证研究发现,与赔偿保险和HMO相比,美国的行为健康例外可以立即大幅降低成本。分拆很快占据了美国行为健康组织市场的很大一部分。与此同时,市场集中度显著提高。方法本文使用行业组织和交易成本文献中的概念和结果来解释(i)为什么分拆比其他制度安排具有成本优势,(ii)为什么这些安排特别适用于行为健康,以及(iii)为什么这种情况没有更早发生。结果主要解释变量与规模经济、避免范围不经济和避免人际关系有关。有时令人惊讶的是,分拆合同中缺乏明确的风险承担和明确的成本降低激励,而获得大额合同所产生的激励则远远克服了这一点。在行为健康方面,分拆的具体优势源于缺乏与其他健康服务的范围经济、提供行为健康方面缺乏规模经济以及管理方面存在规模经济。据推测,行为健康的分拆受益于改变治疗方向的生物医学创新、实现大规模标准化管理的电脑化以及行为健康部门的财务压力。讨论当前研究的实证基础是大量案例研究和心理健康分拆在美国的快速渗透。此类分拆导致的成本降低似乎相当强劲。解释制度变革带来的成本降低必须从为什么旧制度没有实施相同或类似的变革开始。我们强调了在赔偿保险和HMO下,此类变更不可行的原因。然而,我们无法评估这些成本降低可能带来的质量变化。对卫生政策的影响虽然进一步降低成本可能会遵循一条逻辑曲线,这条曲线只是趋于平缓,但一些发展,特别是监管和法律方面的发展,可能会导致分拆成本向其他制度安排下的成本回归。因此,这项研究产生的主要健康政策问题是,应该在多大程度上维持削减成本的自由,以及应该在多小程度上利用成本削减来增加行为健康覆盖率。对进一步研究的启示我认为进一步研究有三个主要途径。第一是为本文提出的假设寻找更多的实证证据。第二个是寻找其他国家和其他医疗保健领域,这些国家和领域的特点有助于应用例外。第三,从质量角度分析了雕花。这里的实证问题是“在美国,分拆对行为医疗质量的影响是什么?”。理论上的问题是“分拆计划的发起人和分拆管理的发起人有什么动机来确保提供高质量的护理?”。版权所有©1999 John Wiley&;有限公司。
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引用次数: 19
Cost-effectiveness in Health and Medicine. By M.R. Gold, J.E Siegel, L.B. Russell, and M.C. Weinstein (eds). New York: Oxford University Press, 1996 保健和医药的成本效益。作者:mr Gold, J.E Siegel, L.B. Russell和M.C. Weinstein(编)。纽约:牛津大学出版社,1996
IF 1.6 4区 医学 Q4 HEALTH POLICY & SERVICES Pub Date : 1999-06-01 DOI: 10.1002/(SICI)1099-176X(199906)2:2<91::AID-MHP46>3.0.CO;2-I
D. Shepard
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引用次数: 38
期刊
Journal of Mental Health Policy and Economics
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