Measuring disparities across the distribution of mental health care expenditures

BACKGROUND

Previous mental health care disparities studies predominantly compare mean mental health care use across racial/ethnic groups, leaving policymakers with little information on disparities among those with a higher level of expenditures.

AIMS OF THE STUDY

To identify racial/ethnic disparities among individuals at varying quantiles of mental health care expenditures. To assess whether disparities in the upper quantiles of expenditure differ by insurance status, income and education.

METHODS

Data were analyzed from a nationally representative sample of white, black and Latino adults 18 years and older (n=83,878). Our dependent variable was total mental health care expenditure. We measured disparities in any mental health care expenditures, disparities in mental health care expenditure at the 95th, 97.5 th, and 99 th expenditure quantiles of the full population using quantile regression, and at the 50 th, 75 th, and 95 th quantiles for positive users. In the full population, we tested interaction coefficients between race/ethnicity and income, insurance, and education levels to determine whether racial/ethnic disparities in the upper quantiles differed by income, insurance and education.

RESULTS

Significant Black-white and Latino-white disparities were identified in any mental health care expenditures. In the full population, moving up the quantiles of mental health care expenditures, Black-White and Latino-White disparities were reduced but remained statistically significant. No statistically significant disparities were found in analyses of positive users only. The magnitude of black-white disparities was smaller among those enrolled in public insurance programs compared to the privately insured and uninsured in the 97.5 th and 99 th quantiles. Disparities persist in the upper quantiles among those in higher income categories and after excluding psychiatric inpatient and emergency department (ED) visits.

DISCUSSION

Disparities exist in any mental health care and among those that use the most mental health care resources, but much of disparities seem to be driven by lack of access. The data do not allow us to disentangle whether disparities were related to white respondent's overuse or underuse as compared to minority groups. The cross-sectional data allow us to make only associational claims about the role of insurance, income, and education in disparities. With these limitations in mind, we identified a persistence of disparities in overall expenditures even among those in the highest income categories, after controlling for mental health status and observable sociodemographic characteristics.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Interventions are needed to equalize resource allocation to racial/ethnic minority patients regardless of their income, with emphasis on outreach interventions to address the disparities in access that are responsible for the no/low expenditures for even Latinos at higher levels of illness severity.

IMPLICATIONS FOR HEALTH POLICIES

Increased policy efforts are needed to reduce the gap in health insurance for Latinos and improve outreach programs to enroll those in need into mental health care services.

IMPLICATIONS FOR FURTHER RESEARCH

Future studies that conclusively disentangle overuse and appropriate use in these populations are warranted.

Pharmacodynamic effects of administration of maytansine conjugated anti-CD22 monoclonal antibodies to cynomolgus monkeys

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Antibody-based B-cell specific therapeutic approaches have revolutionized the treatment of non-Hodgkin's lymphomas (NHL) as well as other hematological malignancies. However, a large variability in clinical response has been observed, and the need to develop effective new treatments remains urgent. A promising approach is the use of antibody-drug conjugates (ADCs), cytotoxic drugs covalently linked to antibodies through specialized chemical linkers for the treatment of NHL. CMC-544, an antibody to a B-cell specific glycoprotein CD22 conjugated to the cytotoxin calicheamicin, has shown clinical activity in patients. In addition, antibodies directed to B-cell targets such as rituximab and epratuzumab are in clinical trials for the treatment of NHL and autoimmune disorders. We have generated10F4v3, an anti-CD22 antibody conjugated to the antimitotic agent maytansine (10F4v3-DM1). DM1 disrupts cellular mitosis through inhibition of tubulin polymerization when internalized into cells. The anti-CD22 DM1 conjugate was shown to have significant potency in preclinical efficacy models of NHL. In order to further characterize this antibody-drug conjugate in preclinical studies, we first evaluated the binding characteristics of the 10F4v3 to peripheral blood B-cells from various geographical sources of cynomolgus monkeys. 10F4v3 bound to peripheral blood B-cells from all cynomolgus monkeys of Indonesian and Mauritian origins, but displayed only limited binding to cynomolgus monkeys of Chinese and Cambodian origins. Therefore, further preclinical evaluation of 10F4v3-DM1 was conducted in Indonesian cynomolgus monkeys to examine the safety, pharmacokinetic, and pharmacodynamic effects in monkeys. B-cells and B-cell subsets were depleted in peripheral blood and lymphoid tissue (spleen, bone marrow) at all doses, with no apparent dose-dependent effects or substantial safety limitations. Based on the nonclinical data, 10F4v3-DM1 exhibits an encouraging pharmacodynamic profile for the potential treatment of non-Hodgkin's lymphoma.

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The health effects of Medicare for the near-elderly uninsured

OBJECTIVE

To determine whether Medicare enrollment at age 65 has an effect on the health trajectory of the near-elderly uninsured.

DATA SOURCES

Eight biennial waves (1992-2006) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51-61 year olds and their spouses.

STUDY DESIGN

We use a quasi-experimental approach to compare the health effects of insurance for the near-elderly uninsured with previously insured contemporaneous controls. The primary outcome measure is overall self-reported health status combined with mortality (i.e., excellent to very good, good, fair to poor, dead).

RESULTS

The change in the trajectory of overall health status for the previously uninsured that can be attributed to Medicare is small and not statistically significant. For every 100 persons in the previously uninsured group, joining Medicare is associated with 0.6 fewer in excellent or very good health (95 percent CI: -4.8, 3.3), 0.3 more in good health (95 percent CI: -3.8, 4.1), 2.5 fewer in fair or poor health (95 percent CI: -7.4, 2.3), and 2.8 more dead (-4.0, 10.0) by age 73. The health trajectory patterns from physician objective health measures are similarly small and not statistically significant.

CONCLUSIONS

Medicare coverage at age 65 for the previously uninsured is not linked to improvements in overall health status.

High subsoil chloride concentrations reduce soil water extraction and crop yield on Vertosols in north-eastern Australia

Salinity, sodicity, acidity, and phytotoxic levels of chloride (Cl) in subsoils are major constraints to crop production in many soils of north-eastern Australia because they reduce the ability of crop roots to extract water and nutrients from the soil. The complex interactions and correlations among soil properties result in multi-colinearity between soil properties and crop yield that makes it difficult to determine which constraint is the major limitation. We used ridge-regression analysis to overcome colinearity to evaluate the contribution of soil factors and water supply to the variation in the yields of 5 winter crops on soils with various levels and combinations of subsoil constraints in the region. Subsoil constraints measured were soil Cl, electrical conductivity of the saturation extract (ECse), and exchangeable sodium percentage (ESP). The ridge regression procedure selected several of the variables used in a descriptive model, which included in-crop rainfall, plant-available soil water at sowing in the 0.90–1.10 m soil layer, and soil Cl in the 0.90–1.10 m soil layer, and accounted for 77–85% of the variation in the grain yields of the 5 winter crops. Inclusion of ESP of the top soil (0.0–0.10 m soil layer) marginally increased the descriptive capability of the models for bread wheat, barley and durum wheat. Subsoil Cl concentration was found to be an effective substitute for subsoil water extraction. The estimates of the critical levels of subsoil Cl for a 10% reduction in the grain yield were 492 mg cl/kg for chickpea, 662 mg Cl/kg for durum wheat, 854 mg Cl/kg for bread wheat, 980 mg Cl/kg for canola, and 1012 mg Cl/kg for barley, thus suggesting that chickpea and durum wheat were more sensitive to subsoil Cl than bread wheat, barley, and canola.

The complexity of medication regimens and test ordering for patients with diabetes from 1995 to 2003

OBJECTIVE

Diabetes care has become increasingly complex. We set out to quantify recent trends in the complexity of medication regimens and test ordering for diabetes patients continuously enrolled in health plans affiliated with a large, regional US health maintenance organization, with representation in the South and Midwest.

RESEARCH DESIGN AND METHODS

We provide descriptive trends analysis of overall diabetes care complexity (number of components [i.e., glucose, blood pressure, cholesterol control], number of medications/tests) from 1995 to 2003 for adults with diabetes (N = 304,233).

MAIN OUTCOME MEASURES

The main outcomes were (1) the proportion of patients receiving diabetes-related medications (blood glucose, blood pressure, and cholesterol control agents), (2) the average number of medications, (3) the proportion of patients receiving diabetes-related tests (glycosylated hemoglobin [HbA1c], urine microalbumin, and serum cholesterol), (4) and the average number of tests ordered within the first year that a patient had any indication of diabetes.

RESULTS

The proportion of patients on cholesterol lowering drugs (18% --> 39%, p < 0.01) and blood pressure lowering drugs (51% --> 62%, p = 0.04) rose significantly, while the proportion on glucose lowering drugs fell (76% --> 47%, p < 0.01). Among patients prescribed medications, the average total number of diabetes-related medications rose from 2.96 to 3.70 medications (p < 0.01) with smaller increases seen for glucose lowering (1.45 --> 1.65, p < 0.01) and blood pressure lowering regimens (2.14 --> 2.51, p < 0.01), and no change for cholesterol lowering drugs (1.23 --> 1.19, p = 0.19). For laboratory tests, the proportion receiving cholesterol (40% --> 58%), and urine microalbumin (4% --> 18%) (all p's < 0.01) rose significantly, while the testing rates for HbA(1c) remained unchanged. The average total number of tests ordered per year increased significantly from 3.34 to 4.10 (p < 0.01) with more modest increases observed for individual tests.

LIMITATION

Trends analyses are unadjusted for many clinical characteristics that might influence the complexity of diabetes care.

CONCLUSIONS

Diabetes care grew more complex with the largest change in the number of patients receiving multi-component diabetes care. While the use of blood pressure and cholesterol lowering drugs rose overall, the proportion of patients using glucose lowering drugs declined and the average number of prescribed glucose lowering drugs did not increase in a clinically significant manner.

Relation of body mass index in young adulthood and middle age to Medicare expenditures in older age

CONTEXT

Increasing prevalence of overweight/obesity and rapid aging of the US population have raised concerns of increasing health care costs, with important implications for Medicare. However, little is known about the impact of body mass index (BMI) earlier in life on Medicare expenditures (cardiovascular disease [CVD]-related, diabetes-related, and total) in older age.

OBJECTIVE

To examine relationships of BMI in young adulthood and middle age to subsequent health care expenditures at ages 65 years and older.

DESIGN, SETTING, AND PARTICIPANTS

Medicare data (1984-2002) were linked with baseline data from the Chicago Heart Association Detection Project in Industry (CHA) (1967-1973) for 9978 men (mean age, 46.0 years) and 7623 women (mean age, 48.4 years) (baseline overall age range, 33 to 64 years) who were free of coronary heart disease, diabetes, and major electrocardiographic abnormalities, were not underweight (BMI <18.5), and were Medicare-eligible (> or =65 years) for at least 2 years during 1984-2002. Participants were classified by their baseline BMI as nonoverweight (BMI, 18.5-24.9), overweight (25.0-29.9), obese (30.0-34.9), and severely obese (> or =35.0).

MAIN OUTCOME MEASURES

Cardiovascular disease-related, diabetes-related, and total average annual Medicare charges, and cumulative Medicare charges from age 65 years to death or to age 83 years.

RESULTS

In multivariate analyses, average annual and cumulative Medicare charges (CVD-related, diabetes-related, and total) were significantly higher by higher baseline BMI for both men and women. Thus, with adjustment for baseline age, race, education, and smoking, total average annual charges for nonoverweight, overweight, obese, and severely obese women were, respectively, 6224 dollars, 7653 dollars, 9612 dollars, and 12,342 dollars (P<.001 for trend); corresponding total cumulative charges were 76, 866 dollars, 100,959 dollars, 125,470 dollars, and 174,752 dollars (P<.001 for trend). For nonoverweight, overweight, obese, and severely obese men, total average annual charges were, respectively, 7205 dollars, 8390 dollars, 10,128 dollars, and 13,674 dollars (P<.001 for trend). Corresponding total cumulative charges were 100,431 dollars, 109,098 dollars, 119,318 dollars, and 176,947 dollars (P<.001 for trend).

CONCLUSION

Overweight/obesity in young adulthood and middle age has long-term adverse consequences for health care costs in older age.

Ambient ozone in forests of the Central and Eastern European mountains

Ambient ozone (O(3)) concentrations in the forested areas of the Central and Eastern European (CEE) mountains measured on passive sampler networks and in several locations equipped with active monitors are reviewed. Some areas of the Carpathian Mountains, especially in Romania and parts of Poland, as well as the Sumava and Brdy Mountains in the Czech Republic are characterized by low European background concentrations of the pollutant (summer season means approximately 30 ppb). Other parts of the Carpathians, especially the western part of the range (Slovakia, the Czech Republic and Poland), some of the Eastern (Ukraine) and Southern (Romania) Carpathians and the Jizerske Mountains have high O(3) levels with peak values >100 ppb and seasonal means approximately 50 ppb. Large portions of the CEE mountain forests experience O(3) exposures that are above levels recommended for protection of forest and natural vegetation. Continuation of monitoring efforts with a combination of active monitors and passive samplers is needed for developing risk assessment scenarios for forests and other natural areas of the CEE Region.

Labor market costs of illness: prevalence matters

We present a model of the labor market effects of health impairments. In particular, we describe several economic models in which health affects worker productivity and the demand for and supply of market labor services. These models provide a framework for estimating the social cost of prevalent health impairments - a necessary step in conducting cost-benefit analyses and in determining the cost-effectiveness of potential health interventions from a broader social perspective. Our approach suggests that several measures used in the literature provide an incomplete and systematically biased assessment of the economic impact of health impairment or of the treatment of illness and impairment. The problem arises because of the reliance on an approximation at the firm level and from the bias from the neglect of the effect of impairment in shifting the labor market equilibrium. If the illness is prevalent, the effects on labor market equilibrium wage rates could be substantial. In addition, many analyses also ignore the effects of illness on producers' surplus.

Services integration and cost-effectiveness

Alcohol treatment services are increasingly combined with other health and social services to address the needs of multiple-problem clients. Hence, it has been of growing policy interest to find the most effective and the most cost-effective ways of linking these services. This symposium presents some recent studies in this area. The small but growing body of studies in this area has great potential to inform public policy debates.

Distribution of ozone and other air pollutants in forests of the Carpathian Mountains in central Europe

Ozone (O3) concentrations were monitored during the 1997-1999 growing seasons in 32 forest sites of the Carpathian Mountains. At all sites (elevation between 450 and 1320 m) concentrations of O3, nitrogen dioxide (NO2), and sulfur dioxide (SO2) were measured with passive samplers. In addition, in two western Carpathian locations, Vychodna and Gubalówka, ozone was continuously monitored with ultraviolet (UV) absorption monitors. Highest average hourly O3 concentrations in the Vychodna and Gubałówka sites reached 160 and 200 microg/m3 (82 and 102 ppb), respectively (except for the AOT40 values, ozone concentrations are presented as microg/m3; and at 25 degrees C and 760 mm Hg, 1 microg O3/m3 = 0.51 ppb O3). These sites showed drastically different patterns of diurnal 03 distribution, one with clearly defined peaks in the afternoon and lowest values in the morning, the other with flat patterns during the entire 24-h period. On two elevational transects, no effect of elevation on O3 levels was seen on the first one, while on the other a significant increase of O3 levels with elevation occurred. Concentrations of O3 determined with passive samplers were significantly different between individual monitoring years, monitoring periods, and geographic location of the monitoring sites. Results of passive sampler monitoring showed that high O3 concentrations could be expected in many parts of the Carpathian range, especially in its western part, but also in the eastern and southern ranges. More than four-fold denser network of monitoring sites is required for reliable estimates of O3 distribution in forests over the entire Carpathian range (140 points). Potential phytotoxic effects of O3 on forest trees and understory vegetation are expected on almost the entire territory of the Carpathian Mountains. This assumption is based on estimates of the AOT40 indices for forest trees and natural vegetation. Concentrations of NO2 and SO2 in the entire Carpathian range were typical for this part of Europe and below the expected levels of phytotoxicity.

Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%

Anemia treatment with epoetin has led to dramatic increases in hematocrit levels since 1989. Studies have demonstrated that morbidity and mortality rates are lower when hematocrit values are within the Disease Outcomes Quality Initiative (DOQI) target range (33 to 36%). Recently, clinical studies demonstrated that patients without cardiovascular disease exhibited lower morbidity rates and improved cognitive function with hematocrit values of >36%. One prospective trial, in contrast, demonstrated that normal hematocrit values among patients with cardiac disease were associated with higher mortality rates. These conflicting results have led to concerns regarding the risks and benefits associated with hematocrit values between 36 and 42%. To address these concerns, a recent cohort of 1996 to 1998 incident hemodialysis patients was studied, with assessments of the risks of death and hospitalization and the medical costs associated with hematocrit values of >36%. Patients survived at least 9 mo after dialysis initiation, and comorbidity, disease severity, and hematocrit levels were determined for months 4 to 9. Patients were grouped on the basis of hematocrit values, i.e., <30, 30 to <33, 33 to <36, 36 to <39, or > or =39%, with 1 yr of follow-up monitoring. A Cox regression model was used to evaluate all-cause and cause-specific mortality and hospitalization rates. The economic evaluations included analyses with Medicare Parts A and B allowable expenditures as the dependent variable and the same clinical characteristics as independent variables. For patients with hematocrit values of > or =36%, mortality rates were not different, hospitalization rates were 16 to 22% lower, and expenditures were 8.3 to 8.5% less, compared with patients with hematocrit values of 33 to <36%. These observations do not demonstrate causality. Additional long-term studies are needed to assess the risks of higher hematocrit values among all patients and patients with cardiovascular disease.

Hematocrit levels and associated Medicare expenditures

Clinical studies and the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines suggest that a target hematocrit of 33% to less than 36% is appropriate for patient benefit. Previous studies have shown an association of lower risks for death and hospitalization when hematocrits were 33% to less than 36%. In this study, we assessed the relationship between hematocrit value and associated Medicare expenditures, analyzing incident Medicare hemodialysis patients from January 1, 1991, through June 30, 1995. All patients survived at least 90 days to normalize eligibility and an additional 6-month entry period to assess comorbidity and hematocrit values. All patients were followed up from July 1, 1991, through December 31, 1996. We assessed the association between hematocrit values in the 6-month entry period and the Medicare-allowable Part A and Part B per-member-per-month (PMPM) expenditures in the follow-up period, controlling for other variables, including patient demographic characteristics, comorbid conditions, and severity of disease. We found that hematocrits of 33% to less than 36% and 36% and higher were associated with lower Medicare-allowable payments in the follow-up period. Compared with reference patients with hematocrits of 30% to less than 33%, the Medicare-allowable PMPM expenditures were significantly greater for patients with hematocrits less than 27% and 27% to less than 30% (12. 7% and 5.3%, respectively), and the Medicare-allowable PMPMs were significantly less for patients with hematocrits of 33% to less than 36% and 36% and higher (6.0% and 8.2%, respectively). Although these findings suggest that the treatment of anemia may be associated with significant savings in total patient Medicare expenditures, caution should be considered because these findings are associations and should not be deemed as showing causality.

Policy evaluation research. Measuring the independent variables

The purpose of this article is to evaluate the accuracy of three methods used to obtain policy data: (a) government agency surveys, (b) secondary sources, and (c) historical legal research. Changes in laws were identified for all 48 contiguous states for the period 1968 to 1994. Legal research is most accurate for well-established laws that have consistent legal descriptions across nearly all states. Laws that are recently enacted, adopted by only a few states, and treated in a legally inconsistent manner across states require a multistage data collection method to identify accurate policy change information.

Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population

BACKGROUND

There is accumulating evidence that screening programs can alter the natural history of colorectal cancer, a significant cause of mortality and morbidity in the US. Understanding how the technology to diagnose colonic diseases is utilized in the population provides insight into both the access and processes of care.

METHOD

Using Medicare Part B billing files from the state of Michigan from 1986 to 1989 we identified all procedures used to diagnose colorectal disease. We utilized the Medicare Beneficiary File and the Area Resource File to identify beneficiary-specific and community-sociodemographic characteristics. The beneficiary and sociodemographic characteristics were, then, used in multiple regression analyses to identify their association with procedure utilization.

RESULTS

Sigmoidoscopic use declined dramatically with the increasing age cohorts of Medicare beneficiaries. Urban areas and communities with higher education levels had more sigmoidoscopic use. Among procedures used to examine the entire colon, isolated barium enema was used more frequently in African Americans, the elderly, and females. The combination of barium enema and sigmoidoscopy was used more frequently among females and the newest technology, colonoscopy, was used most frequently among White males.

CONCLUSION

The existence of race, gender, and socioeconomic disparities in the use of colorectal technologies in a group of patients with near-universal insurance coverage demonstrates the necessity of understanding the reason(s) for these observed differences to improve access to appropriate technologies to all segments in our society.

Changes in the process of care for Medicaid patients with schizophrenia in Utah's Prepaid Mental Health Plan

OBJECTIVE

Changes in the process of psychiatric care received by Medicaid beneficiaries with schizophrenia were examined after the introduction of capitated payments for enrollees of some community mental health centers (CMHCs) under the Utah Prepaid Mental Health Plan.

METHODS

Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the records of 200 patients in nonparticipating CMHCs, which remained in a fee-for-service reimbursement arrangement. Using the Process of Care Review Form, trained abstracters gathered data characterizing general patient management, social support, medication management, and medical management before implementation of the plan in 1990 and for three follow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by treatment site.

RESULTS

By year 3 at the CMHCs participating in the plan, psychotherapy visits decreased, the probability of a patient's terminating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the probability of treatment for a month or longer with a suboptimal dosage of antipsychotic medication increased. Only modest changes in the process of care were observed at the nonplan CMHCs.

CONCLUSIONS

Change in the process of psychiatric care was more evident at the sites participating in the plan, where traditional therapeutic encounters were de-emphasized in response to capitation. The array of changes raises questions about the vigor of care provided to a highly vulnerable group of patients.

Hospitalization for gastrointestinal and liver diseases: the effect of socioeconomic and medical supply factors

A growing body of research has documented significant variation in health care use between communities. As the health care system is transformed, providers and payers should understand the interaction between a community, its sociodemographic characteristics, and its use of health resources. We describe the association between a population's demographic, socioeconomic, and medical resources and hospital use related to gastrointestinal and liver diseases. We used an all-payer hospital discharge database for Michigan from 1986 to 1988. We identified all medical and surgical hospital admissions during this period from two of the Diagnostic Related Group, Major Diagnostic Categories: No. 6, Diseases and Disorders of the Digestive System; and No. 7, Diseases and Disorders of the Hepatobiliary System and Pancreas. We analyzed age- and sex-specific use rates. Finally, we analyzed the influence of sociodemographic variables from the Area Resource File at the county level, on hospital use, using a Poisson regression model. We noted a significant association between increased hospitalizations and increased age in a community. Hospital beds per capita did not influence admission rates overall, although more hospital beds were associated with more medical admissions. Overall, the total physician supply was associated with more admissions. Finally, the most important socioeconomic variable was education. As the level of education of a county increased, hospital admissions decreased dramatically. The transformation of the health care delivery system presents opportunities and challenges. Understanding the underlying epidemiology of disease and how it interacts with a community's socioeconomic and medical resources or medical supply characteristics will be necessary to meet the community's health needs and to ensure the financial viability of providers. This is especially true when payers use a standard payment in a region, such as Medicare's managed care payment, without adjustments for the underlying population characteristics known to influence use.

Expenditures for mental health services in the Utah Prepaid Mental Health Plan

This article examines the effect of a mental health carve-out, the Utah Prepaid Mental Health Plan (UPMHP), on expenditures for mental health treatment and utilization of mental health services for Medicaid beneficiaries from July 1991 through December 1994. Three Community Mental Health Centers (CMHCs) provided mental health services to Medicaid beneficiaries in their catchment areas in return for capitated payments. The analysis uses data from Medicaid claims as well as "shadow claims" for UPMHP contracting sites. The analysis is a pre/post comparison of expenditures and utilization rates, with a contemporaneous control group in the Utah catchment areas not in the UPMHP. The results indicate that the UPMHP reduced acute inpatient mental health expenditures and admissions for Medicaid beneficiaries during the first 2 1/2 years of the UPMHP. In contrast, the UPMHP had no statistically significant effect on outpatient mental health expenditures or visits. There was no significant effect of the UPMHP on overall mental health expenditures.

Perspectives on Alcohol Taxation

The issue of alcohol taxation can be viewed from several angles: public health, revenue generation, economic efficiency, fairness, and effects on employment. Conclusions about when an alcohol tax increase is appropriate or effective-or by how much a tax should be increased-differ widely, however, depending on which of these perspectives is taken. Policymakers trying to find a balance among the different perspectives must weigh the multiple trade-offs involved when a tax increase is proposed. Considerations include how different drinking populations respond to tax-induced higher alcohol prices, the equity of a tax for all members of society, and the effects of displacement for workers in alcohol-related industries.

Rural hospital networks: implications for rural health reform

This article summarizes the perspectives gained in the course of evaluating a 4-year demonstration program that supported rural hospital networks as mechanisms for improving rural health care delivery. Findings include: (1) joining a network is a popular, low-cost strategic response for rural hospitals in an uncertain environment; (2) rural hospital network survival is enhanced by the mutual resource dependence of members and the presence of a formalized management structure; (3) rural hospitals join networks primarily to improve cost efficiency but, on average, hospitals do not appear to realize short-term economic benefit from network membership; and (4) some of the benefits of these networks may be realized outside of the communities in which rural hospitals are located.

Utah's Prepaid Mental Health Plan: the first year

This DataWatch analyzes the effect of the Utah Prepaid Mental Health Plan (UPMHP) on use of mental health services by and mental health treatment expenditures for Medicaid beneficiaries from July 1991 to June 1992. During this period three community mental health centers (CMHCs) provided mental health services to Medicaid beneficiaries in their catchment areas in return for capitated payments. Utilization and expenditure rates per beneficiary per month were analyzed using a "fixed-effects" statistical modeling approach, controlling for categories of beneficiary, time trends, seasonal effects, and CMHC grouping (capitated urban, capitated rural, noncapitated urban, and noncapitated rural). The results of the analysis suggest that the UPMHP reduced admissions for inpatient mental health treatment, inpatient mental health expenditures, and total mental health expenditures for Medicaid beneficiaries. These findings must be regarded as preliminary because of the relatively short time period covered by the data.

The uses of outcomes research for medical effectiveness, quality of care, and reimbursement in type II diabetes

Randomized controlled trials (RCTs), such as the Diabetes Control and Complications Trial (DCCT), usually evaluate the efficacy of a single treatment strategy. The DCCT, for example, evaluates intensive diabetes management aimed at achieving glucose levels as close to normal as possible to modify specific pathophysiological outcomes--specifically, the development or worsening of microvascular disease. In contrast, longitudinal observational studies, such as the type II diabetes Patient Outcome Research Team (PORT) study, address medical effectiveness; that is, how well prevailing treatments work in clinical practice settings. The PORT relies heavily on patient-reported measures of general and diabetes-specific health status, in addition to using complications as major study outcomes. In the type II diabetes PORT, 4,000 patients with type II diabetes and a wide range of socioeconomic, demographic, and disease characteristics, from three widely dispersed geographic settings and varying systems of care, are being followed for a 2.5-year period. Data are collected from periodic self-administered patient questionnaires and from administrative data bases. In the PORT study, nonmutable confounders, such as case-mix, and potentially mutable features, such as patients' preferences for treatment, health habits, regimen adherence, family support, and physician's interpersonal style, are carefully measured. The PORT study will examine the effectiveness of preventive care and established disease treatment in relation to eye, cardiovascular, and extremity disease, measuring and relating use of health-care services to patient outcomes. The results have the potential for maximizing quality of care and minimizing use of services in type II diabetes by matching physician-level profiles of patient outcomes with medical-care-process data and making this information accessible to practicing physicians.