Quality of care: past achievements and future challenges.

The heightened attention currently given to quality of care offers a unique opportunity for major advances. But to make the most of it, the greater energy and resources now available have to build on what is already known about quality of care, rather than largely ignore and therefore rediscover what has been learned in the past about, for example: how quality can be defined and measured, the relation between outcomes and the process of care, and the distinction between quality assessment and determinations of efficacy. If future efforts are rooted in what is known about these and other aspects of quality of care, they can yield substantial insights into how to improve quality, rather than simply how to measure it, and how to do it for more than inpatient hospital care.

Costs of mandates for outpatient mental health care in private health insurance.

Various methods for estimating the cost of mandated mental health benefits have been devised, each resulting in substantially different estimates. These methods neglect to distinguish between the two components of cost to the insurer: social cost (due to increased utilization) and shifted cost (from other sources of payment). We apply a method we developed for estimating the two types of costs of mandates for outpatient mental health services that integrates data from insurers with information from the literature on financing of mental health services. We applied our method to legislation recently proposed in Massachusetts that would double the mandated minimum benefit level from +500 to +1,000. We expect payments by the largest carrier in the state to increase by a factor of 1.65. More than half of this increase represents shifted costs rather than new costs to society.

Reductions in coverage for mental and nervous illness in the Federal Employees Health Benefits Program, 1980-1984.

After nearly 15 years of nondiscriminatory coverage, the largest plan in the Federal Employees Health Benefits Program cut its coverage of care for mental illness disproportionately to coverage for other health care in 1981 and 1982. "Catastrophic" coverage for inpatient mental illness care was introduced by many of the plans in 1984. The authors review the reductions in coverage from economic and clinical perspectives, highlighting the impact of the disparity between the coverage for mental illness and other medical conditions. The model of catastrophic protection for treatment of mental illness set forth in the Federal Employees Health Benefits Program does not bode well for the patient and family who must cope with such a financial contingency.

An analysis of the heterogeneity of U.S. nursing home patients.

Research has shown that the nursing home patient population is quite heterogeneous in terms of both individual patient characteristics and service needs. Furthermore, existing administrative classifications do a poor job of representing this heterogeneity. As a consequence we have conducted an analysis of the individual and service characteristics of two types of patients represented in the National Nursing Home Survey of 1977 (i.e., patients whose primary source of payment was Medicare and patients whose primary payment source was not Medicare). In this analysis we identified patterns of individual characteristics within the two patient groups and showed how these patterns related to their service needs. The logic of the model permitted us both to establish patterns of characteristics within the two payment types and to examine the implications of individual heterogeneity remaining in the classification. This makes the methodology useful both as a research tool for understanding the nature of the nursing home population and as a tool for studying the consequences of various classification schemes for questions of identifying service patterns and needs as well as the evaluation of policy options.

Costs of training and maintenance of expert man-power vs costs of drugs. Priorities in the field of helminthic diseases in developing countries.

In developing countries, prevention and treatment of parasitic diseases present not only a challenge to the health services but also a test case to the efficiency of health education in general. In these countries, medical schools have started and continue to function on a Western pattern of medical education. This may have well served the provision of hospital-based services on a well-tested scientific and professional tradition. The system is, however, inappropriate when it comes to the provision of preventive care and mass treatment, and to the introduction of adaptational and developmental changes which are constantly needed in developing countries as well on the health service as on the educational side. As a consequence the whole enterprise is in danger of becoming increasingly irrelevant and insufficient. The fact that both health services and medical curricula are at present seriously questioned in developed countries as well, lends an even greater importance to their re-assessment and adaptation in developing countries.

Brazilian health care financing and health policy: an international perspective / Brazilian health care financing and health policy: an international perspective

This study reviews financial aspects of health care in Brazil with some comparisons with more developed countries. Brazil now spends less than five percent of GDP on health, but that share has risen substantially in recent years. There are substantial inequities between regions in service availability and in health status; current policy actions are aimed at correcting deficiencies of this system. The blend of private and public financing and service delivery has resulted in an unsatisfactory level of productivity and efficiency for health care programs. The role of the medical professions and, broadly, the supply of phisicians have been inappropriate to national health-care needs. The paper identifies a number of areas in which further analysis and policy development will be essential to achieve goals of equity and efficiency for the health-care system