Integrating mental health services through reimbursement reform and managed mental health care

People with serious and persistent mental illness require a range of community services typically provided by different specialized agencies. At the clinical level, assertive team case management is the strategy commonly used to achieve integration of services across specialized sectors. The USA also has used various financial and organizational approaches to reduce fragmentation and increase effectiveness, including development of stronger public mental health authorities, use of financial incentives to change professional and institutional behavior, requirements to allocate savings from hospital closures to community systems of care, and introduction of mental health managed care on a broad scale. These approaches have potential but also significant problems and there is often a large gap between theory and implementation. These US developments are discussed with attention to the implications for mental health services in the UK.     

The German health care system and health care reform

This article presents a structured survey of the German health care and health insurance system, and analyzes major developments of current German health policy. The German statutory health insurance system has been known as a system that provides all citizens with ready access to comprehensive high quality medical care at a cost the country considered socially acceptable. However, an increasing concern for rapidly rising health care expenditure led to a number of cost-containment measures since 1977. The aim was to bring the growth of health care expenditure in line with the growth of wages and salaries of the sickness fund members. The recent health care reforms of 1989 and 1993 yielded only short-term reductions of health care expenditure, with increases in the subsequent years. 'Stability of the contribution rate' is the uppermost political objective of current health care reform initiatives. Options under discussion include reductions in the benefit package and increases of patients' co-payments. The article concludes with the possible consequences of the 1997 health care reform of which the major part became effective 1 July 1997.     

Inequities in health care: a five-country survey

This paper reports the results of a comparative survey in five nations: Australia, Canada, New Zealand, the United Kingdom, and the United States. The survey finds a high level of citizen dissatisfaction with the health care systems in all five countries. Citizens with incomes below the national median were more likely than were those with higher incomes to be dissatisfied. In contrast, relatively few citizens reported problems getting needed health care. Low-income U.S. citizens reported more problems getting care than did their counterparts in the other four countries.     

Primary mental health care reform: Catch the wave

There is growing energy behind primary mental health care reform – from political activity, research, funding and clinical practice. The evidence that early adopters have been busy reforming mental health services in primary health care is apparent in the rise of references to primary mental health care and collaborative care in national and provincial planning documents, clinical trials examining the efficacy of collaborative mental health care, funded clinical programs across the country, and the establishment of a nationally funded initiative – the Canadian Collaborative Mental Health Initiative – to research and develop tools to implement collaborative mental health care. In conclusion, there is real momentum in primary mental health care reform. Health care planners and executives will want to turn their attention to collaborative care as the benefits to individuals and their families, the health care system, and to the economy are clear.     

Inequities in access to health care in South Africa

Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n = 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.     

Policy challenges in US health care system reform

Once again, efforts are being made to overhaul the US health care system. Democrats and Republicans have conflicting views on how to repair this ailing system. However, this is not a new phenomenon. Reformers have long struggled to form a universal health care system only to find themselves in conflict with groups whose financial stake is threatened as well as numerous labor associations who are concerned about a loss of power. This struggle is also caused by differences in ideologies. This article surveys social movements for national health insurance (NHI) that occurred in the United States and will examine features that prevented NHI policy formation.     

Restructuring health care financing in Chile

The current Chilean government adopted a neoclassical model of development and subsequently introduced various incentives for the privatization of medical care. This paper analyzes health care financing in Chile during the last decade and evaluates government efforts to minimize state-financed medical care. In so doing, this paper provides a framework for analyzing private vs public medical care delivery systems in developing countries. For this reason, the first section discusses the major attributes and issues of public and private delivery systems followed by a case study examining the origins, effectiveness and impact of the restructured health system in Chile.     

Payment system reform for health care providers in Korea

Since its introduction in 1977, the national health insurance programme in Korea has paid health care providers on a fee-for-service basis. Regulated fee-for-service payment has resulted in an increased volume and intensity of medical care. It has also distorted the input mix of treatment because physicians have substituted more profitable and uninsured (no coverage) medical services for those with lower margins, as is evidenced by the sharp increase in the caesarean delivery rate. This paper examines two recent supply-side reforms in Korea: Diagnosis Related Group (DRG) and Resource-based Relative Value (RBRV). Since 1997, through a pilot programme covering a selected group of diseases for voluntarily participating health care institutions, the DRG-based prospective payment system has proven to be effective in containing cost with little negative effect on quality. RBRV-based payment was implemented in 2001, but led to an almost uniform increase in fees for physician services without a mechanism to control the volume and expenditure. Challenges and future issues in the reform of the payment system in Korea include the expansion of benefit coverage, quality monitoring and improvement, strategic plans to overcome the strong opposition of providers and the introduction of global budgeting.     

Psychiatry reform: analysis of power relations in mental health care services

This paper approaches the topic of Psychiatric Care Reform in Brazil and, particularly, in the State of Rio Grande do Sul, as well as the role played by a disciplinary power in modern society. We believe that in spite of the implementation of a reform in Psychiatric care and the growing progress in the legislation aimed at protecting psychiatric patients, such individuals are still the objects and the instruments inside relationships of disciplinary power. This study is based on Michel Foucalt's works, especially on his analysis of the power relationships, in order to elicit answers to our main question, to support the thesis we formulated, and to reach our goal, which is to ponder on the discrepancy we perceive between legal victories and the new speech delivered by the psychiatric care reformers, and on a practice which seems to deny emancipation to psychiatric sufferers, that is, deny their citizenship.     

Health promotion and health care system reform in Poland

The development of health promotion is determined by the defined changes of health situation of population, which occur in time. Contemporary methods of health promotion were initiated in 1970's, when the problem of increase of civilization (behavioural) diseases strongly related to lifestyles, was noticed. Health promotion programmes in Poland in spite of many achievements in the conceptualization phase, encounter difficulties in implementation, because of lack of appropriate structural solutions and financial support for this important public health area.     

Prevention in Poland: health care system reform.

Despite the political and economic reforms that have swept Eastern Europe in the past 5 years, there has been little change in Poland''s health care system. The Ministry of Health and Social Welfare has targeted preventive care as a priority, yet the enactment of legislation to meet this goal has been slow. The process of reform has been hindered by political stagnation, economic crisis, and a lack of delineation of responsibility for implementing the reforms. Despite the delays in reform, recent developments indicate that a realistic, sustainable restructuring of the health care system is possible, with a focus on preventive services. Recent proposals for change have centered on applying national goals to limited geographic areas, with both local and international support. Regional pilot projects to restructure health care delivery at a community level, local health education and disease prevention initiatives, and a national training program for primary care and family physicians and nurses are being planned. Through regionalization, an increase in responsibility for both the physician and the patient, and redefinition of primary health care and the role of family physicians, isolated local movements and pilot projects have shown promise in achieving these goals, even under the current budgetary constraints.     

公共卫生保障体系的建立与农村卫生改革

SARS的肆虐,使我们看到了建立公共卫生保障体系的迫切性;“三农”问题的日益突出,使农村卫生改革变得更加刻不容缓。把公共卫生保障体系的建立与农村卫生的改革有机地融合在一起,是一个新的思路,也是一个新的课题。本文试图对此作初步的探讨。     

我国医疗体制改革的经济学分析

从公共经济学的视角,对我国医疗卫生体制改革失败的事实进行分析,得出我国医疗体制改革失败的根本原因在于市场与政府的双失灵.认为破解医改的难题,关键在于纠正市场与政府的双失灵.     

Quality and customers: Type 2 change in mental health delivery within health care reform

The traditional separation of mental health and medical programs is problematic because mental health issues are inseparable from the larger medical system. By contrast, a collaborative primary care model of mental health care, augmented and supported by secondary specialty mental health services, has the potential to optimize quality and cost goals while reinforcing health care reform principles. The flexibility of mental health treatment in this delivery structure provides opportunities to customize services according to patient and purchaser expectations. with the Hay Group Inc.     

Foundations' roles in transforming the mental health care system

This paper highlights topics explored in a meeting of health grantmakers and mental health experts convened by America's HealthTogether in February 2006. The meeting's aim was to review the evidence on the burden of mental illness, explore the causes and consequences of a poorly functioning mental health care system, and stimulate discussion about philanthropy's role in responding to a national call for transformation of that system. The meeting identified several priorities for foundation work. Examples of current work in these areas, from Grantmakers In Health's Resource Center database, are presented.