Carl A. Taube

DRGs in psychiatry. An empirical evaluation.

On October 1, 1983, Medicare began paying general hospitals by a prospective payment system based on DRGs. Psychiatric settings are exempted automatically or by request. By January 1985, however, a decision is required on how to integrate psychiatric settings into this system. This article provides an empirical analysis of the current DHHS DRGs categories for mental disorders. Current mental disorder DRGs and alternate DRGs examined here explain less than 3-12% of the variation in psychiatric length of stay. This is in contrast to 30-50% explained variation for other disorders. Alternatives and policy implications are discussed.

The Effect of Medicaid on Access to Ambulatory Mental Health Care for the Poor and Near-Poor Under 65

Analysis of the National Medical Care Utilization and Expenditure Survey indicates that the poor/near-poor with continuous Medicaid coverage had almost double the probability of use of ambulatory mental health care compared with the poor/near-poor not enrolled in Medicaid. The higher probability of use reflects the impact of increased financial accessibility to needed mental health services and may also be influenced by an associated demand for social services provided by organized mental health settings in addition to clinical services. Intensity of use per user was not significantly different between Medicaid- and non-Medicaid-enrolled poor/near-poor, but the percent paid out of pocket was substantially lower for those continuously in Medicaid.

The Use of Ambulatory Services by Persons With and Without Phobia

The delivery of ambulatory mental health and general health services to persons with phobias (unweighted n=1,689) and without phobias during a 6-month period are examined. The phobics were part of a larger study of 18,572 subjects, drawn as a representative sample of the population in five locations, as part of the Epidemiologic Catchment Area Program (ECA). Among phobic conditions, agoraphobia most often leads to use of services related to emotional problems, especially in the specialty mental health sector. There were no significant differences between male and female subjects in their use of the various sectors for a mental health reason. The highest age group of agoraphobics that used health services most often was 25-44 years old, and the group that used them least often was 65 years and older. Agoraphobics with four or more symptoms of panic use services in higher proportions than agoraphobics with zero to three panic symptoms. The authors observe that a very large proportion of phobics report seeking no help from any source.

Community mental health centers and the treatment of severe mental disorder.

Between 1970 and 1975 the number and rate of admissions to community mental health centers of people given a diagnosis of schizophrenia increased dramatically. However, the proportion of patients with schizophrenia admitted to community mental health centers declined because the increase in the rate of admissions of patients with schizophrenia was diluted by the large increase in the rate of admissions of patients with other diagnoses. The authors review the data on trends in admissions of patients with a diagnosis of schizophrenia in the context of an expanding system of mental health services characterized by changes in the locus of care.

The severely mentally Ill in General Hospital psychiatric units

Analysis of data from the NIMH Survey of Discharges from Non-Federal General Hospitals found that severely mentally ill patients (those with schizophrenia, other psychoses, paranoia, and major affective disorders) became an increasingly larger proportion of general hospital discharges between 1970 and 1980, with more change observed between 1975 and 1980. This seems to confirm that general hospital care is replacing at least some of the care previously provided in State mental hospitals. There has been an increase in beds in nongovernment-owned general hospitals and a decrease in beds in state hospitals. In addition, while discharge referrals from government general hospitals for severe patients were made predominantly to state hospitals in 1970, in 1980 this was rarely the case.

Technical and allocative efficiency in production of outpatient mental health clinic services

This paper presents an analysis of production of ambulatory mental health services in free standing outpatient clinics. The study empirically addresses several issues including: the nature of returns to scale, the impact of differing organizational forms on the volume of service produced and the efficiency of staffing patterns used by psychiatric clinics. An appraisal of two popular production functions is offered based on predictive performance. The results suggest the existence of decreasing returns to scale; input hiring decisions that depart from cost minimization; and the potential important of a decentralized clinic organization for expansion of access to mental health services.

The economics of mental health services through 1986: Empirical studies

In the last ten years health economists have turned their attention to the field of mental health services delivery. In particular, the responsiveness of the demand for ambulatory mental health care relative to the price, the economic costs of mental disorder, and the effects of prospective payment systems have received major attention. This article reviews these studies and suggests areas for future development.

The decision to seek an exemption from PPS.

This paper examines the receipt of exemptions from Medicares Prospective Payment System (PPS) for distinct part psychiatric units of general hospitals. A logit model of the exemption status of 1,045 psychiatric units is estimated using 1984 data. The results suggest that units that were expected to profit from a change in payment method (cost based on PPS) were least likely to obtain an exemption from PPS.

Deinstitutionalization in the United States

from treatment innovations of the period: models of milieu treatment and aftercare programs that appeared to offer practical alternatives to long-term custodial care [3]. Changes in psychosocial treatment, coupled with the introduction of neuroleptic medications, permitted the first large-scale changes in the public hospital system. In 1955, the resident census in state and county psychiatric hospitals began the steady decline that has persisted into the present. Deinstitutionalization, in its most literal sense, had begun. In 1963 the United States Congress passed the Community Mental Health Centers Act and instituted the first national policy of community care for the mentally ill. This legislation established community mental health centers to provide a standard range of local services in selected federal catchment areas throughout the United States. The goals of community care were ambitious, going far beyond the notion of hospital reform. They included not merely the relocation of the mentally ill in more humane settings but the rehabilitation of psychiatric patients and their reinsertion into society. They emphasized prevention of the behaviors associated with longterm hospitalization and, through this, eventual elimination of the