Access to mental health services for active duty and National Guard TRICARE enrollees in Indiana.

Mental health problems are a well-known consequence of combat exposure, and the problem of barriers to receiving mental health care for veterans is well known. The current heavy reliance on reserve component soldiers may aggravate this problem. This study tries to characterize problems with access to mental health care for activated members of the National Guard reserve component, active duty service members, and their families in the state of Indiana. Data from a telephone survey of Indiana mental health providers listed in the TRICARE provider revealed that only 25% were accepting new TRICARE patients, although regression analyses revealed that acceptance of patients was positively related to market population and negatively related to the number of deployed soldiers in the market. The primary barrier to obtain care appears to be the accuracy of the TRICARE provider list.

The impact of federal bioterrorism funding programs on local health department preparedness activities.

Using the 2005 National Association of County and City Health Officers Profile of Local Health Departments data set, bivariate probit and Heckman selection models were used to test the hypothesis that the level of federal funding received for bioterrorism preparedness is related to the preparedness activities undertaken by local health departments. Overall budget, leadership, and crisis experience are found to be the most important determinants of local preparedness activity, but Centers for Disease Control and Prevention preparedness funding plays a mediating role by building capacity through the hiring of one key leadership position, the emergency preparedness coordinator. Additional research is needed to determine the potential impact of these funds on other aspects of the local public health system, such as the scope of services delivered, to determine secondary effects of the program.

Regulation, financial incentives, and the production of quality.

An economic model for the production of health care quality is presented, encompassing financial and altruistic returns, penalties and rewards, and transaction costs. After maximizing returns from quality and service volume, the role of regulatory policies and pay-for-performance proposals in producing quality is examined. The tension between the production of quantity and quality is demonstrated. Specifically, the model shows that increasing the costs of a quality improvement program reduces program effectiveness, sanctions for low quality will not improve the performance of high-quality providers, noncompliance with regulation can be a rational decision, and some pay-for-performance programs will not improve quality for low-quality providers. The model suggests incentive structures to improve quality for all providers. This model has application to a variety of social regulatory programs of importance in public health and health care, including health care quality (ie, regulation of nursing homes or medical laboratories) and environmental and food safety regulation.

The Impact of a Telephone-Based Chronic Disease Management Program on Medical Expenditures.

The impact of a payer-provided telephone-based chronic disease management program on medical expenditures was evaluated using claims data from 126,245 members in employer self-ensured health plans (16,224 with a chronic disease in a group enrolled in the self-management program, 13,509 with a chronic disease in a group not participating in the program). A random effects regression model controlling for retrospective risk, age, sex, and diagnosis with a chronic disease was used to determine the impact of program participation on market-adjusted health care expenditures. Further confirmation of results was obtained by an ordinary least squares model comparing market- and risk-adjusted costs to the length of participation in the program. Participation in the program is associated with an average annual savings of $1157.91 per enrolled member in health care expenditures. Savings increase with the length of participation in the program. The results support the use of telephone-based patient self-management of chronic disease as a cost-effective means to reduce health care expenditures in the working-age population. (Population Health Management 2016;19:156-162).

Physician evaluations of care management practices in Medicaid programs.

OBJECTIVE: To assess differences in care management practices for Medicaid beneficiaries in predominantly commercial and predominantly Medicaid health plans. STUDY DESIGN: Physicians in the networks of 8 managed care plans participating in Medicaid programs were surveyed regarding the availability and usefulness of care management practices and the overall quality of care management. The responses of physicians in plans serving predominantly Medicaid enrollees were contrasted with the responses of physicians in predominantly commercial plans who cared for Medicaid enrollees. METHODS: Logistic regression analysis was used to calculate adjusted odds ratios relating to the availability of care management practices. Multiple regression techniques were used to construct comparisons of adjusted means relating to the usefulness of practices and the overall quality of care management. RESULTS: Physicians in predominantly commercial plans reported greater availability of care management practices. No patterns of differences were noted in ratings of the usefulness of practices if available. Physicians in predominantly commercial plans rated the quality of care management higher than physicians in predominantly Medicaid plans. However, there remains room for substantial improvement for commercial and other Medicaid contracting plans. CONCLUSIONS: Commercial plans add value to Medicaid programs, and efforts to discourage their withdrawal from participation are justified. However, physician evaluations support the potential for better care management in all types of contracting plans.

Practice patterns of testing waived under the clinical laboratory improvement amendments.

OBJECTIVES: To determine operational practices in laboratories operating under a Certificate of Wavier (waived laboratories), or equivalent, under the Clinical Laboratory Improvements Amendments (CLIA) of 1988 when performing tests designated as having an insignificant risk of an erroneous result (ie, waived tests). METHODS: Waived laboratories that were part of the Centers for Disease Control and Prevention Laboratory Sentinel Monitoring Network project in the states of Arkansas, New York, and Washington were surveyed about their quality control (QC) and quality assurances (QA) practices when performing waived testing. Arkansas and Washington sent out similar questionnaires, whereas on-site surveys were conducted in New York. The survey in Arkansas and Washington also included nonwaived laboratories. The New York visits were designed to pilot test a regulatory inspection program for limited testing sites, which, in New York, are roughly equivalent to laboratories operating under a CLIA Certificate of Wavier and/or Provider-Performed Microscopy but are generally not located in physicians' offices. Laboratories visited in New York were selected from a list of limited testing sites and were representative of that population. RESULTS: Arkansas received responses from 211 facilities (37% response rate), of which 38% had Certificates of Waiver. Washington received responses from 190 waived laboratories (71% response rate) and from 116 nonwaived laboratories (32% response rate). In New York, 607 of the 2751 limited testing laboratories were visited. Reporting laboratories in all 3 states most frequently performed testing for glucose, urinalysis, urine human chorionic gonadotropin, occult blood, and group A Streptococcus antigen, although other waived tests were performed less frequently. Washington found that 57% of waived laboratories followed manufacturers' QC requirements. Arkansas found that 58% of laboratories doing waived tests that required liquid controls performed these controls, and 59% performing waived testing requiring electronic controls used these controls. In New York, 68% of the laboratories complied with the manufacturer's QC requirements for a variety of tests. Being accredited by an external organization or affiliated with a more complex laboratory improved compliance. Nonwaived laboratories in Washington and Arkansas complied with manufacturer's instructions at a higher rate than did waived laboratories. Similar deficiencies in following CLIA requirements were found in other areas of laboratory operation. CONCLUSIONS: Just more than half of waived laboratories in 3 diverse states follow manufacturer's instructions for recommended QC and QA. These instructions help ensure that the test will produce results that have an insignificant chance of an error. Although we did not study the impact of this and other findings on patient care, the results show that imposing good laboratory practices by regulation alone was insufficient to ensure quality laboratory results in any location evaluated. A system that can continually provide accessible education on laboratory practices, coupled with new thoughts on the regulatory environment, is in order.