Medical necessity and psychiatric managed care.

The concept of medical necessity is a provision of commercial insurance contracts and federal government Medicaid requirements that limits the payment to only those services that are essential for treating a person's sickness, injury, or condition. The concept of medical necessity is one tool used by third-party payers to contain their financial risk in a seemingly nonarbitrary manner. Also, the definitions of medical necessity used by commercial insurers or by the federal government reflect their product's or program's philosophies. Expanding commercial insurance or Medicaid psychiatric coverage would require changing those philosophies. As long as society is faced with a greater demand for health-related service than resources to meet them, such systems of rationing will be used. Even with full parity for psychiatric benefits, mechanisms will be used by payers to limit or control demand, thereby controlling financial risk. The short-term challenge for psychiatric advocates is to secure the most acceptable definitions of medical necessity from third-party payers. The long-term challenge for MH/SA advocates and for all health care advocates, is to develop a system that pays for the greatest number of quality services for the greatest number of people in need, in an affordable manner, regardless of diagnosis.

Perspective on the integration of substance user needs assessment and treatment planning.

In the 1970s and 1980s, several techniques for assessing the needs for substance user treatment were developed. Generally these techniques relied upon the data developed from large-scale data-gathering systems, originally designed to assess the capacity of the substance user treatment system nationwide. The need assessment techniques generally require making estimates of the prevalence of substance use disorders in the population and then applying them to the national utilitization experience. As first attempts often do, these approaches tended to simplify complex problems and tended to rely too heavily on the only available data. The result was that they tended to reify current practice rather than to define best practice. In the 1990s, new challenges face those attempting to assess needs for substance user services. As a result of the last decade's emphasis on cost containment, new concepts have challenged traditional views of needs assessment. This paper will discuss those new concepts and their impact on the needs assessment endeavor. In particular, the impact of the concept of medical necessity will be examined.

Photooxidation of tryptophan: O2(1 delta g) versus electron-transfer pathway.

Tris (2,2'-bipyridyl)ruthenium(II)chloride hexahydrate (Ru[bpy]3(2+)) free in solution and adsorbed onto antimony-doped SnO2 colloidal particles was used as a photosensitizer for a comparison of the O2(1 delta g) and electron-transfer-mediated photooxidation of tryptophan (TRP), respectively. Quenching of excited Ru(bpy)3(2+) by O2(3 sigma g-) in an aerated aqueous solution leads only to the formation of O2(1 delta g) (phi delta = 0.18) and this compound was used as a type II photosensitizer. Excitation of Ru(bpy)3(2+) adsorbed onto Sb/SnO2 results in a fast injection of an electron into the conduction band of the semiconductor and accordingly to the formation of Ru(bpy)3(2+) and was used for the sensitization of the electron-transfer-mediated photooxidation. The Ru(bpy)3(3+) is reduced by TRP with a bimolecular rate constant kQ = 5.9 x 10(8) M-1 s-1, while O2(1 delta g) is quenched by TRP with kt = 7.1 x 10(7) M-1 s-1 (chemical + physical quenching). Relative rate constants for the photooxidation of TRP (kc) via both pathways were determined using fluorescence emission spectroscopy. With Np, the rate of photons absorbed, being constant for both pathways we obtained kc = (372/Np) M-1 s-1 for the O2(1 delta g) pathway and kc > or = (25,013/Np) M-1 s-1 for the electron-transfer pathway, respectively. Thus the photooxidation of Trp is more than two orders of magnitude more efficient when it is initiated by electron transfer than when initiated by O2(1 delta g).

Antibody-targeted photolysis: in vitro immunological, photophysical, and cytotoxic properties of monoclonal antibody-dextran-Sn(IV) chlorin e6 immunoconjugates.

A set of anti-melanoma immunoconjugates were prepared which contained chlorin e6: antibody molar ratios of 18.9:1, 11.2:1, 6.8:1, and 1.7:1. All immunoconjugates retained antigen binding activity regardless of the chromophore:antibody substitution ratio that was attained. In contrast, the ground-state absorption spectra of the immunoconjugates showed features which appeared to be dependent on the chromophore:antibody molar ratio. In addition, the quantum yield of singlet oxygen generated by the conjugated chromophores was observed to be significantly less than that observed with the unbound dye. Time-resolved absorbance spectroscopy of the chromophore excited triplet state indicated that the loss of singlet oxygen quantum yield resulted from diminished chromophore triplet yield. Analysis of data obtained from in vitro photolysis of target melanoma cells, in combination with that obtained from the immunochemical and photochemical studies, indicates that the observed immunoconjugate phototoxicity can be reasonably quantitatively represented by (1) the ability of the immunoconjugate to bind SK-MEL-2 cell surface antigen, (2) the amount of chromophore localized at the target cells by immunoconjugate binding, (3) the delivered dose of light at 634 nm, and (4) the singlet oxygen quantum yield of the antibody-bound photosensitizer. Though these data argue strongly for photolysis by the cumulative dosage of singlet oxygen at the cell membrane, nonetheless, the concurrent photoinduced release of other cytotoxic agents should not be ruled out.

Photoproperties of alkoxy-substituted phthalocyanines with deep-red optical absorbance.

Triplet-state properties of 1,4,8,11,15,18,22,25-octa-n-butoxyphthalocyanine and its zinc derivative were determined for the first time. The T1 state of the metal-free phthalocyanine was characterized by a short lifetime (tau T = 17 microseconds) and low quantum yield (phi T = 0.095), and quenching of the triplet by O2 occurred with a bimolecular rate constant (kT sigma = 1.3 x 10(8) M-1 s-1) that is indicative of an endogonic reaction. The zinc complex (ZnPc(OBu)8) was markedly better as a triplet photosensitizer with respect to both tau T (60 microseconds) and phi T (0.5). Quenching by O2 produced singlet oxygen with nearly 100% efficiency, and kT sigma (1.7 x 10(9) M-1s-1) was close to the spin-statistical diffusion-controlled limit. Phosphorescence measurements showed the energy of the T1 state of ZnPc(OBu)8 to be 100 kJ/mol, which is 6 kJ/mol above the 1 delta g state of O2. These photoproperties, together with Q-band absorption maxima in the mid-700 nm range indicate that metal-centered 1,4,8,11,15,18,22,25-octaalkoxyphthalocyanines have excellent potential as sensitizers in photodynamic therapy.

Alcoholism and drug abuse service forecasting models: a comparative discussion.

Several demand-based models for forecasting alcoholism/drug abuse bed needs have been developed over the past few years. Demand models have inherent problems for predicting future needs because of the unknown relationship between the demand group and the nondemand group. Nonetheless, these models hold promise for the alcoholism/drug abuse service system because of some of the unique characteristics of that system. Three models for forecasting alcoholism bed need and one for forecasting drug abuse bed need are discussed; the strengths and weaknesses of each are presented. Projections for the same geographic area are compared. Criteria for selecting one model over another are also recommended.

Predicting alcoholism manpower needs.

In response to the needs both to develop new, nonduplicative alcoholism services and to contain cost, and in order to plan for the labor-intensive alcoholism treatment system, planning techniques are needed to assist in the rational planning for and allocation of manpower. Using data from the 1980 National Drug and Alcoholism Treatment Utilization Survey, it is possible to analyze the staffing patterns of various modalities of alcoholism treatment. Two regression equations were developed to identify key variables for predicting manpower needs in various facilities. Budget, service type, and treatment capacity were statistically significant predictions of direct-care FTE staff in inpatient/residential units. The best predictive ability for direct-care FTE staff in detoxification and longer-term residential facilities was obtained with a general regression model which was based on all types of services (e.g., detoxification, longer-term residential, and outpatient). For outpatient settings, however, direct-care FTE staff was best predicted by considering budgets and treatment capacities within outpatient settings only. Based on this study, a planner can predict, with reasonable confidence, FTE direct-care staff by varying the values of the independent variables in the regression equation to reflect the various characteristics of the services being planned.

Predicting alcoholism service needs from a National Treatment Utilization Survey.

Even when the prevalence of alcohol abuse and alcoholism allows for resource allocation based on differential problem size, further planning methods are necessary in order to determine what specific types of services should be developed to meet the estimated need. Using population-based variables (e.g., total population, White and minority populations) and easily obtainable alcohol indicator variables (consumption, revenue, alcohol-related deaths and arrests), regression models were developed to predict state bed capacity data, obtained from the 1980 National Drug and Alcoholism Treatment Utilization Survey (NDATUS). Prediction models are presented for detoxification, quarterway and halfway house, other residential, hospital, and outpatient. Several variables, particularly total population, deaths, and arrests, are predictive of alcoholism service levels by state, as reflected on NDATUS. Based on this study, estimates of specific service needs within a geographic area can be made by varying the values of the independent variables in the models to reflect the characteristics of the area.

Planning alcoholism services: a technique for projecting specific service needs.

In response to an increasing emphasis on health services planning, a technique for projecting in-residence and outpatient alcoholism treatment and rehabilitation needs has been developed. This technique relies on services data from 34 comprehensive alcoholism treatment programs, funded by the National Institute on Alcohol Abuse and Alcoholism. For in-residence services, the methodology involves an analysis of the use of available in-residence services such that it is possible to determine how many beds of a given service type are needed to serve those admitted to the treatment system. Because all who come in contact with the system do not need or receive services, it is possible to calculate how many beds of a given service type are needed to serve each person coming in contact with the system. This is called the "beds per contact." The product of the beds per contact times the number in the identified target population is the number of beds of a given type needed to serve the target population. A similar methodology is used to project outpatient service needs. The assumptions underlying this technique, and its advantages and disadvantages, are discussed.

Systems planning for the 80s: the Nebraska Mental Health Desired Service System model.

In an effort to address the complex realities of mental health service delivery in the 1980s, a systems model for planning and policy making has been developed. The model, called "the Nebraska Mental Health Desired Service System," can serve as a template for future service delivery system design. The development of the model and issues attendant to it are presented. Application of the model to planning, fiscal management, system management, politics, human resources development, and services coordination is presented.

Photosensitized electron transport across lipid vesicle walls: Enhancement of quantum yield by ionophores and transmembrane potentials.

The photosensitized reduction of heptylviologen in the bulk aqueous phase of phosphatidylcholine vesicles containing EDTA inside and a membrane-bound tris(2,2'-bipyridine)ruthenium(2+) derivative is enhanced by a factor of 6.5 by the addition of valinomycin in the presence of K(+). A 3-fold stimulation by gramicidin and carbonyl cyanide m-chlorophenylhydrazone is observed. The results suggest that, under these conditions, the rate of photoinduced electron transfer across vesicle walls in the absence of ion carriers is limited by cotransport of cations. The rate of electron transfer across vesicle walls could be influenced further by generating transmembrane potentials with K(+) gradients in the presence of valinomycin. When vesicles are made with transmembrane potentials, interior more negative, the quantum yield of heptylviologen reduction is doubled, and, conversely, when vesicles are made with transmembrane potentials, interior more positive, the quantum yield is decreased and approaches the value found in the absence of valinomycin.

Photosensitized electron transport across lipid vesicle walls: quantum yield dependence on sensitizer concentration.

An amphiphilic tris(2,2'-bipyridine)ruthenium(2+) derivative that is incorporated into the walls of phosphatidylcholine vesicles photosensitizes the irreversible oxidation of ethylenediaminetetraacetate(3-) dissolved in the inner aqueous compartments of the vesicle suspension and the one-electron reduction of heptylviologen(2+) dissolved in the continuous aqueous phase. The quantum yield of viologen radical production depends on the phospholipid-to-ruthenium complex mole ratios. A kinetic model is used to derive an order-of-magnitude estimate for the rate constant of electron transport across the vesicle walls. The results are inconsistent with a diffusional mechanism for electron transport and are interpreted in terms of electron exchange.

Rate of alcoholism diagnoses in community mental health centers: the effect of the presence of an alcoholism treatment program.

In this study, it was hypothesized that community mental health centers (CMHCs) with distinct alcoholism treatment programs (ATPs) would diagnose alcohol problems at a greater frequency than would centers without ATPs. It was also hypothesized that psychoses, personality disorders, and transient situational disturbances would be diagnosed more frequently in CMHCs without ATPs. Yearly diagnostic admission data from nine of Nebraska's CMHCs (four with ATPs, five without) were used. It was found that CMHCs with ATPs diagnosed significantly more alcohol problems than did CMHCs without ATPs (23.5% vs 4.2%). In addition, it was found that CMHCs with ATPs diagnosed significantly lower totals of transient situational disturbances than did CMHCs without ATPs. No differences were found between CMHCs on totals of other diagnostic categories. Practical implications and several alternative explanations for the findings are discussed.