The impact of risk shifting and contracting on mental health service costs in California.

This paper identifies the impact of "program realignment," a 1991 California state policy that significantly enhanced local governments' financial risk and programmatic authority for public mental health services, on treatment costs per user, and on the mix of inpatient and outpatient service costs. The study employs a natural pre-realignment and post-realignment design using the 59 California local mental health authorities (LMHAs) as the unit of analysis over a seven-year period spanning policy implementation. Total treatment and inpatient cost per user decreases and outpatient cost per user increases after program realignment. Higher levels of contracting with private providers tend to enhance this trend, while risk for institutional services reduces user costs uniformly. Financial and programmatic decentralization can enhance cost efficiency in treatment, while promoting substitution of outpatient services for inpatient services. Local conditions such as risk and contracting determine the extent of the policy response.

Medicaid-eligible children who don't enroll: health status, access to care, and implications for Medicaid enrollment.

We estimate that 17% of Medicaid-eligible children in the United States are uninsured, with 27% covered by private insurance. Uninsured children have become a target for state outreach and enrollment efforts. However, the effort may not be a worthwhile use of resources if these children have sufficient access to primary care and are able to enroll in Medicaid should serious health problems arise. This analysis of health status, access to care, and use of preventive and other services suggests otherwise. Although the uninsured Medicaid-eligible children are slightly healthier than their enrolled counterparts, they face reduced access to care and lower rates of service use. After controlling for health status and other characteristics, we find that being uninsured increases the likelihood of being without a usual source of care by eight percentage points, and increases reporting of unmet needs by seven percentage points. Being uninsured also decreases by nine percentage points the proportion of children with any health provider visits, and increases by 12 percentage points the proportion with family out-of-pocket expenses exceeding $500. These findings lend support to the hypothesis that the enrollment process is onerous for some families. Targeted efforts to enroll uninsured Medicaid-eligible children could help in reducing the effect of barriers and reducing differences in access to care.

Managed care and fee discounts in psychiatry: new evidence.

This article describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.

Treatment of vascular lesions in pigmented skin with the pulsed dye laser.

BACKGROUND: Vascular lesions occurring in African-American patients are often not treated because of the risk of local side effects. OBJECTIVE: The study was to determine the efficacy of the flashlamp-pumped dye (FLPD) laser in the treatment of vascular malformations in African-American patients. METHODS: All lesions in three patients were treated with the FLPD laser using a 585 nm wavelength, 5 mm spot size, 450 pulse width, and fluences ranging from 6.5 to 8.5j per cm2. CONCLUSION: The FLPD was effective in treating vascular malformations. Transient changes in colour and skin texture occurred at the treated sites.

Subcutaneous nodules caused by Pseudomonas aeruginosa without sepsis.

Pseudomonas aeruginosa infection can cause a wide array of skin manifestations. While some infections are mild, as are the cases with hot tub folliculitis and toe web or nail infection, others are a result of sepsis and can be fatal without prompt treatment. The classic skin finding of P. aeruginosa sepsis is Ecthyma gangrenosum, but other signs such as papules, petechiae, and hemorrhagic bullae can also be seen. Suppurative panniculitis can also be caused by P. aeruginosa sepsis and clinically manifests as solitary or multiple subcutaneous nodules. Reports in the literature describe these nodules in the setting of clinical sepsis or with positive blood cultures. We report a case of localized subcutaneous nodules on the leg caused by P. aeruginosa in a patient without sepsis or positive blood cultures. The source of the infection was thought to be from a traumatic inoculation. This raises the possibility that P. aeruginosa can cause subcutaneous nodules from a localized infection, perhaps via lymphangitic spread without the manifestations of sepsis.

Medicaid and service use among homeless adults.

This paper examines the effect of Medicaid recipiency on the level and site of medical service use among homeless single men and women in New York City. Simple regressions of Medicaid on service use indicate that Medicaid significantly increases the likelihood that homeless individuals receive services, especially emergency and inpatient hospital services. In further analyses that control for health status, use instrumental variables procedures, and examine differences between a similar population in 1985 and 1987, we find that Medicaid neither increases nor diminishes access to emergency rooms. We find some evidence suggesting that Medicaid does improve access to nonhospital medical care.

Changing supply and earning patterns of the mental health workforce.

The authors examine recent trends in the supply and earnings of various mental health providers from 1989 to 1995. The makeup of the mental health workforce is fundamentally different now than a decade ago. The number and earnings of psychiatrists have been relatively flat. The number of psychologists increased by 24%, with their earnings rising rapidly in the 1980s, and remaining level since 1990. The number of clinically trained social workers increased by 87% over the same period, and the number of advanced practice nurses certified in mental health specialties almost doubled, with the earnings of these master's-level providers increasing steadily over the period described. These trends are discussed in the context of major changes in the financing and delivery of mental health care.

Children's access to mental health care: does insurance matter?

Using data from a 1992 community survey of children and their parents (or guardians), we found major gaps in mental health insurance coverage. Interestingly, private insurance had no statistically significant effect on use of mental health services. Youth without insurance coverage and those with public insurance had higher rates of serious emotional disorder than did those with private insurance. The analysis is based on the National Institute of Mental Health's Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, conducted in three mainland U.S. sites and in Puerto Rico.

Moist wound healing with occlusive dressings. A clinical review.

BACKGROUND: Occlusive dressings have become increasingly popular in the management of wound care. Numerous types of occlusive dressings are presently available for the treatment of acute and chronic wounds. Occlusion enhances wound healing primarily by preventing wound dessication. As a result, epidermal necrosis and eschar formation do not occur, and wounds reepithelialize more quickly. OBJECTIVE: Choosing a dressing to meet the specific needs of the patient can often become confusing for the physician. We review the various types of occlusive dressings and their advantages and disadvantages in the practical management of acute and chronic wounds. METHODS: A literature review of the subject was performed. RESULTS: Occlusive dressings enhance reepithelialization by preventing wound dessication. Lower infection rates are generally achieved despite bacterial proliferation under some occlusive dressings. CONCLUSION: Occlusive dressings simplify wound care and are an excellent choice in the management of most acute and chronic wounds. This review should enable the clinician to choose the best dressing to meet the individual wound of the patient.

Carbon dioxide laser treatment of pitted acne scarring.

Laserabrasion has been shown to have limited application in the treatment of acne scarring. Focal laserabrasion used to treat individual pitted acne scars may have broader clinical application. We present 8 patients with pitted acne scars who were treated with either conventional continuous wave carbon dioxide (CO2) laser, or with the superpulsed CO2 laser, or both. Cosmetically acceptable results were attained, particularly in the patients treated with the superpulsed laser.

Carbon dioxide laser treatment of chronic actinic cheilitis.

The carbon dioxide laser in both conventional and superpulsed modes was used to treat 13 patients with chronic actinic cheilitis. The procedure was well tolerated. Focal, but not functionally restricting, scarring developed in three patients. The cosmetic result was otherwise excellent. No recurrences have been noted.

Multiple squamous cell carcinomas in lesions of discoid lupus erythematosus.

Squamous cell carcinoma (SCC) is the most common skin cancer in black patients. In half of the cases, it is associated with predisposing factors. We present a patient who has been evaluated for thirty-nine years with a diagnosis of discoid lupus erythematosus (DLE) and has multiple SCCs. The lesions occurred in chronic hyperkeratotic lesions of DLE.