Hospital & community psychiatry最新文献

This paper reviews problems that the Medicaid program poses for health care reformers and how the Clinton plan would deal with them. The Clinton plan represents a compromise between preserving or expanding the Medicaid program and eliminating. The plan would seek to extend services to those without insurance and reduce health care costs, partly by limiting services and increasing out-of-pocket costs for Medicaid beneficiaries. All Medicaid beneficiaries would be included in the same basic system of health care that the plan proposes for other Americans. All current beneficiaries would remain eligible for Medicaid, but services would be reduced for many of them. However, services that are important for persons with severe mental illness would be maintained. The plan also would increase out-of-pocket costs for premiums and services, and these increases could be significant for some beneficiaries.

Objective: The authors' goal was to review current published literature on the psychiatric hospitalization of adolescents with a diagnosis of conduct disorder.

Methods: The English-language literature from 1980 to 1991 cited in the MEDLINE database was searched using the key words conduct disorder, adolescent psychiatric hospitalization, psychiatric hospitalization criteria, adolescent psychiatric inpatient hospitalization, and adolescent psychiatric admissions.

Results: A diagnosis of conduct disorder or presenting symptoms and behaviors consistent with that diagnosis are commonly reported for adolescent psychiatric admissions. Estimates of the percentage of admissions to psychiatric inpatient treatment facilities of adolescents with conduct disorder or symptoms consistent with that disorder range from 30 to 70 percent. There are no research-based criteria for hospitalization of adolescents for conduct disorder, and systematic studies of the outcome of psychiatric hospitalization for this group have not been published. Comorbid psychiatric diagnoses and similar behavioral symptoms in conduct disorder and comorbid disorders complicate inpatient treatment of adolescents with conduct disorder.

Conclusions: Studies of the outcome of psychiatric hospitalization of adolescents for conduct disorder are needed to determine the appropriate use of this modality.

Implementation of the Clinton Administration's proposed Health Security Act could significantly increase the number of seriously mentally ill persons enrolled in health maintenance organizations (HMOs). Studies of the mental health status and outcomes of seriously mentally ill persons treated in HMOs show conflicting findings and provide little guidance about the likely effect of the Health Security Act on this population. However, implementation of the Health Security Act would be likely to influence the treatment of seriously mentally ill persons by altering the activities of state and local governments in the financing and delivery of care, facilitating the integration of public and private services, and encouraging development of additional service capacity. To clarify HMOs' likely role in providing services to seriously mentally ill persons under health care reform, more research is needed on the current service capacity of HMOs, on treatment approaches and outcomes in different HMO models, on whether seriously mentally ill persons would be likely to choose HMOs from among health plan options, and on whether higher-income HMO enrollees would seek care outside HMO provider networks.

Shortly after his election in 1992, President Clinton appointed a health care reform task force to develop a proposal for providing health care benefits for all American citizens and legal residents. Between February and May 1993 the Interdepartmental Working Group, composed of more than 30 working groups addressing specific health care issues, prepared options for the task force. The Health Security Act was introduced in November 1993. Besides universal coverage and a basic benefit package, provisions included health insurance reform, regional alliances for structuring competition among health insurance plans, consumer choice of health plans, and provisions for Medicaid beneficiaries. Proposed mental health and substance abuse provisions included coverage of intensive nonresidential services, medical management, evaluation and assessment services, and case management. Initial limitations on coverage of inpatient mental health services and psychotherapy would be removed by 2001. The Clinton plan also called for integration of public mental health and substance abuse services into the full range of health services offered by local health plans. Major issues that will have to be resolved if health care legislation is to be enacted include whether regional alliances should be mandatory and whether employers should be required to contribute to insurance premiums.

People with psychiatric disabilities have articulated a model of recovery that encourages their empowerment by emphasizing consumer-defined goals, liberty, self-control of symptoms, peer support, elimination of discrimination, and provision of adequate material and social supports. Application of this model to health care reform requires public education to fight discrimination, an end to the use of involuntary interventions in the name of treatment, further development of services run by survivors-consumers and other alternatives to psychiatric hospitalization, and increased involvement of survivors-consumers in decisions related to their treatment and support. To promote empowerment of people with mental health problems, health care reform should include affordable, universal coverage without exclusions for preexisting high-risk conditions, parity of mental health benefits with other benefits, which includes coverage for voluntary services only, and incentives for funding long-term care, alternatives to hospitalization, and holistic healing services.