The economics of public health: financing drug abuse treatment services

Drug abuse treatment financing exhibits a heterogeneous set of sources from federal, state, and local governments, as well as private sources from insurance, patient out-of-pocket, and charity. A public health model of drug abuse treatment is presented for a market that can be characterized by excess demand in many communities and an implied policy of rationing. According to best estimates, as many as 6.7 million individuals may need treatment, but only an estimated 1.5 million individuals actually participated in treatment episodes. Since, as demonstrated empirically, drug abuse treatment has a robust and positive social net benefit to society, it is perplexing that treatment financing stops with a rationing outcome that inhibits social welfare. The justification for public financing is centered on the external costs of drug addiction, but subsidization is grounded in the reality that a large number of addicted individuals do not have sufficient resources to pay for treatment out-of-pocket, nor do they have private insurance coverage. Social welfare losses are generated by financial arrangements that are inconsistent with rational budgeting theory and as such would lead to non-optimal organization and management of the drug abuse treatment system.     

Expanding the research infrastructure for lesbian health.

Interest in research about lesbian health has increased dramatically since the late 1980s and gained national attention in 1999 when the Institute of Medicine published the groundbreaking report Lesbian Health: Current Assessment and Directions for the Future. In March 2000, the Department of Health and Human Services and partner organizations presented the Scientific Workshop on Lesbian Health, during which invited experts on lesbian health worked with federal representatives to develop action steps to implement recommendations in the Institute of Medicine report. National priorities were thus established for the emerging field of lesbian health research. Although researchers of various sexual orientation and gender identities will contribute to this field, lesbian researchers have a unique perspective and an important role to play. This commentary focuses on the preparedness of these individuals to respond to challenges set forth by the Institute of Medicine and Scientific Workshop reports. Despite differences in their academic backgrounds, lesbian researchers have reported common experiences and needs. Substantial proportions have encountered barriers because they were lesbians or conducted lesbian research, and many expressed willingness to mentor others, to help others to conduct research about lesbians, or both.     

Medicaid support of alcohol, drug abuse, and mental health services

Medicaid expenditures for alcohol, drug abuse, and mental health (ADM) services in 1984 were examined for the States of California and Michigan. Persons receiving such services constituted 9 to 10 percent of the total Medicaid population in the two States and accounted for 22 to 23 percent of total Medicaid expenditures. ADM expenditures were 11 to 12 percent of the total. Although the two States had similar proportions of overall expenditures for these services, Michigan appeared to emphasize inpatient psychiatric care, while California emphasized ambulatory and nursing home care. Based on the experience of the two States, national Medicaid expenditures for ADM services exclusive of long-term care were estimated to be $3.5 to $4.9 billion in 1984, two to three times the level suggested by earlier estimates.     

On-site primary care and mental health services in outpatient drug abuse treatment units

Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between these units' organizational features and the degree to which they provided onsite primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with more dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services.     

Concepts in social research: links with the field of health services evaluation

This paper discusses theories and research perspectives from the social sciences and their role in constituting the field of "health services evaluation". The objective is to present less explored theoretical fields such as the "comprehensive" and "dialectical" approaches. Finally, the study presents a methodological proposal based on a qualitative approach to the evaluation of health services and projects.     

Mental health and substance abuse services in the era of health care reform

In the face of the cost crisis in the U.S. health care delivery system and in the era of reform, mental health and substance abuse services are in jeopardy. As the Clinton health reform plan is being debated during the months ahead, however, advocates for mental health and substance abuse care can play an important role in preserving benefits. To do so, they must press on with research into the effectiveness and cost-effectiveness of all aspects of mental health and substance abuse treatment; they must focus energies on working with managed care companies to ensure the provision of only necessary care at the appropriate level and intensity; and they must strive toward understanding the reforms being proposed and the implications for mental health and substance abuse services. Successful integration of the full array of mental health and substance abuse services into a generic benefits package remains a realistic goal, but the challenge is formidable.     

Public sector managed care for substance abuse treatment: Opportunities for health services research

Observations of reduced utilization of alcohol and drug abuse treatment following the introduction of managed behavioral health care suggest that substance abuse services may be especially responsive to managed care restrictions and limits. In publicly funded treatment systems, patient attributes, system and provider characteristics, and financing mechanisms may heighten susceptibility to unintended effects. The State Substance Abuse and Mental Health Treatment Managed Care Evaluation Program reviewed state managed care programs for publicly funded alcohol and drug treatment services and is evaluating programs in Arizona, Iowa, Maryland, and Nebraska. The article describes initiatives and outlines evaluation activities. It discusses the opportunities and challenges of assessing public managed care plans.