The successful application of medical offset in program planning and in clinical delivery.

Medical cost offset was discovered in the health maintenance organization (HMO) setting over 35 years ago and was used not only to justify the earliest instances of the inclusion of mental health treatment as a benefit, but also was used in program design and development. With the new emphasis on outcomes research, medical cost offset remains a viable method of conducting nonintrusive studies of efficacy, efficiency, and quality. Through the use of the research design described, an early HMO delivery system developed 68 focused, target behavioral interventions that years later became the basis for emerging managed mental health care.

Medical costs, Medicaid, and managed mental health treatment: the Hawaii study.

In a randomized, prospective design with Medicaid enrollees, managed mental health treatment reduced medical services costs and utilization by 23 to 40 percent relative to control groups. For enrollees with chronic medical diagnoses, managed treatment reduced medical costs by 28 to 47 percent, while medical costs for fee-for-service enrollees increased by 17 percent. For enrollees without chronic medical diagnoses, traditional fee-for-service also reduced medical costs by about 20% but used three times as many outpatient visits. Costs of managed treatment were recovered in 6 to 24 months, suggesting that managed mental health treatment should be incorporated in health reform initiatives.

The future of psychotherapy: one psychologist's perspective.

The inefficient manner in which psychotherapy is delivered renders mental-health practitioners vulnerable to the new emphasis in health-cost containment. It is estimated that in 1995 most health-care delivery will be controlled by five or six giant health corporations. Fifty percent of the mental-health practitioners in independent practice today are unlikely to survive. Those who do survive will either have learned the new delivery system, or they will be employees of corporate health. As frightening as these predictions may seem, there is also a window of opportunity for psychotherapists to get their house in order and to meet the challenge.

Rheumatic fever and gonococcal pharyngitis in an adult.

The arthritis of rheumatic fever in adults may mimic acute gonococcal arthritis. To further characterize this clinical picture the features of six patients presenting with the migratory polyarthritis of acute rheumatic fever have been analyzed. There were two men and four women, ranging in age from 18 to 43; in five the initial clinical impression was gonococcal arthritis. In all patients, however, the diagnosis of acute rheumatic fever was subsequently established. Characteristics of acute rheumatic fever not commonly described included tenosynovitis in all six and an erythematous rash in three. In three patients synovial fluid WBC exceeded 28,000/cu mm, with greater than 90% neutrophils. In five of the six, gonococcal arthritis was ruled out by appropriate studies and by failure to respond to antibiotics in all patients. The one patient with serum antigonococcal antibodies had gonococcal pharyngitis and acute rheumatic fever.

Detection of antisalivary duct antibody from Sjögren's syndrome by an autoradiographic method.

A new technique to detect anti-salivary duct antibody (ASDA) has been developed by using autoradiographic, rather than immunofluorescent methods. The antibody activity detected by autoradiography is probably classic ASDA. Both techniques may be consecutively performed on the same tissue section without attenuation of either. Some of the potential advantages of the radiolabelling of ASDA are pointed out, and a few preliminary experiments using the labelled antibody as a marker are presented.

Behçet syndrome with "aphthous colitis".

A 46-year-old man with Behçet syndrome and a long history of recurrent bouts of colitis was studied by sigmoidoscopy, barium enema x-ray film, and colon biopsy. A nonspecific colitis characterized by shallow mucosal ulcerations and submucosal mononuclear infiltration in the absence of meaningful roentgenolographic changes was seen. A histopathological comparison was made between the oral and colonic lesions. The aphthous colitis appears, therefore, to be a colonic manifestation of Behçet syndrome, differing from typical chronic nonspecific ulcerative colitis in terms of clinical course, severity, and histologic appearance. The simultaneous occurrence of Behçet syndrome and inflammatory disease of the colon was discussed in terms of the differential diagnosis of colitis.