Bringing the Social Sciences to Health Policy: An Appreciation of David Mechanic.

David Mechanic has been a pioneering leader in the social and behavioral sciences of health, health services, and health and mental health policy for more than fifty years. One of David's most distinctive qualities has been his vision in identifying trends and defining new research areas and perspectives in health care policy. His early work on how methods of physician payment by capitation and fee-for-service in England and the United States affected physicians' responses to patients and patient care addressed present challenges and many ongoing studies of payment mechanisms. His papers on rationing of health care established a framework for examining alternative allocation mechanisms and just decision making. Influential papers dealt with risk selection, policy challenges in managed care, reducing racial disparities, trust relationships between patients, doctors, and the public and health institutions, and the predicaments of health reform. Focusing on the implementation of the Affordable Care Act, David explored its opportunities and challenges especially in providing comprehensive and effective behavioral health services. A hallmark of his work has been his redirecting our attention to the most severely ill and those in greatest need. Less visible is the leadership and institution building endeavors and the many honors David has received.

Examining critical health policy issues within and beyond the clinical encounter: patient-provider relationships and help-seeking behaviors.

Among notable issues in health care policy and practice over the past 50 years have been those centered on the changing dynamics in clinical encounters, predominantly the relationship between physicians and patients and access to health care. Patient roles have become more active, diverse, long-term, and risk-based, while patient-provider relationships are multifaceted, less paternalistic, and more pivotal to health outcomes. Extensive literatures on help-seeking show how much social influences affect both undertreatment and inappropriate high utilization of health care. The challenge in trying to contain the growth of health care costs is two-fold: developing better ways of defining need for care and promoting better access for those who could benefit most from health care. Both of these strategies need to be considered in the context of addressing racial, ethnic, socioeconomic, and health status disparities. Rebuilding the primary care sector as a sociologically informed strategy and a key component of health care reform may optimize both health care delivery and patient outcomes.

Interventions to improve medication adherence in schizophrenia.

OBJECTIVE: Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice. METHOD: Studies were identified by computerized searches of MEDLINE and PsychLIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized. RESULTS: Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on nonadherence involved an array of supportive and rehabilitative community-based services. CONCLUSIONS: Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.