Emerging Trends In Mental Health Policy And Practice

Mechanic, David

doi:10.1377/hlthaff.17.6.82

Cited by 45 publications

(20 citation statements)

References 28 publications

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“…Finally, better linkages between hospitals and outpatient mental health and substance abuse services may help Profile A patients break the pattern of repeated rehospitalizations for underlying mental health issues. 40,41 Both low-SES patients and society at large have a stake in addressing health disparities and lowvalue use. The shifting health policy landscape might offer the opportunity to use workforce, delivery, and payment innovations to address the fundamental causes of health disparities and costly hospital use among this population.…”

Section: Discussionmentioning

confidence: 99%

Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care

Kangovi

Barg

Carter³

et al. 2013

Health Affairs

372

286

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Patients with low socioeconomic status (SES) use more acute hospital care and less primary care than patients with high socioeconomic status. This low-value pattern of care use is harmful to these patients' health and costly to the health care system. Many current policy initiatives, such as the creation of accountable care organizations, aim to improve both health outcomes and the cost-effectiveness of health services. Achieving those goals requires understanding what drives lowvalue health care use. We conducted qualitative interviews with forty urban low-SES patients to explore why they prefer to use hospital care. They perceive it as less expensive, more accessible, and of higher quality than ambulatory care. Efforts that focus solely on improving the quality of hospital care to reduce readmissions could, paradoxically, increase hospital use. Two different profile types emerged from our research. Patients in Profile A (five or more acute care episodes in six months) reported social dysfunction and disability. Those in Profile B (fewer than five acute care episodes in six months) reported social stability but found accessing ambulatory care to be difficult. Interventions to improve outcomes and values need to take these differences into account. R educing avoidable hospitalizations and emergency department (ED) visits is a major target for cost control and quality improvement in the health care system. Hospitalizations for ambulatory care-sensitive conditions 1 -that is, acute conditions that could have been prevented or mitigated by effective ambulatory care 2 -cost approximately $30.8 billion annually.3 At each stage of care, patients with low socioeconomic status (SES) are at higher risk for being hospitalized for ambulatory care-sensitive conditions than patients of higher socioeconomic status.1-7 Low-SES patients are twice as likely as high-SES patients to require urgent ED visits, 4,8 four times more likely to require admission to the hospital, 1-3 and more likely to return to the hospital after discharge 6,7,9,10 and require multiple hospitalizations for any given illness.11 At the same time, they use 45 percent less ambulatory 12 and preventive care 13,14 than high-SES patients. Un-and underinsurance drive low-SES patients' preferential use of inpatient health services in part. 1,[15][16][17][18] But even in countries with near-universal health insurance coverage, lowvalue use persists among low-SES patients. 19This suggests that factors beyond insurance shape preferences for inpatient versus ambulatory care.The relative underuse of primary care and overuse of hospital-based care among low-SES patients, which we call "low-value use," has two negative consequences. First, these patients are less likely to gain the health benefits of primary care, 20,21 exacerbating health disparities.

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Section: Discussionmentioning

confidence: 99%

Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care

Kangovi

Barg

Carter³

et al. 2013

Health Affairs

372

286

View full text Add to dashboard Cite

show abstract

“…During the 1960s, many medical insurance plans began to include psychotherapy as a partially reimbursable expense, and private insurance paid for about one-quarter of outpatient treatment (Horwitz, 2002). During the 1970s, the rate of private insurance coverage continued to rise, and the federal Medicaid program also became a major source of payment for therapy (Mechanic, 1998). The economic basis of the therapeutic relationship was no longer solely between therapists and their clients but had come to involve private and public third-party payers.…”

Section: The Crisis Of Legitimacy In Psychiatrymentioning

confidence: 99%

DSM-III and the revolution in the classification of mental illness

Mayes¹,

Horwitz²

2005

J. Hist. Behav. Sci.

436

230

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A revolution occurred within the psychiatric profession in the early 1980s that rapidly transformed the theory and practice of mental health in the United States. In a very short period of time, mental illnesses were transformed from broad, etiologically defined entities that were continuous with normality to symptom-based, categorical diseases. The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was responsible for this change. The paradigm shift in mental health diagnosis in the DSM-III was neither a product of growing scientific knowledge nor of increasing medicalization. Instead, its symptom-based diagnoses reflect a growing standardization of psychiatric diagnoses. This standardization was the product of many factors, including: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases. This article endeavors to explain the origins of DSM-III, the political struggles that generated it, and its long-term consequences for clinical diagnosis and treatment of mental disorders in the United States.

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“…Such criteria are often used aggressively to reduce inpatient use, because hospital treatment is the most expensive psychiatric service. 3 A set of medical-necessity criteria continued to be applied to this patient's care when he was discharged to an intensive outpatient setting. The criteria for this level of care were somewhat ambiguous and subjective, as the services included supervision from residential counselors and a structured psychosocial day program.…”

Section: Clinical Realitymentioning

confidence: 99%