The dynamics of managed mental health care.

Presented here is an exploration of the motivations involved in the development and application of managed mental health care to the private practice of outpatient psychotherapy. The interaction of management policy and psychotherapy is conceptualized in a dynamic model designed to provide insights into effective care policies. The model is described first, then the development of managed care, which appears defensive and is becoming symptomatic to the point of needing significant change. It is suggested that management policies providing choices of therapists and therapies will be the most effective in addressing ethical, fiscal, and psychological concerns of funders, consumers, and providers.

Cost-benefit analysis for the use of Haemophilus influenzae type b conjugate vaccine in Santiago, Chile.

Cost-benefit analyses can be integral to the evaluation of interventions in developing countries. The authors compare the potential benefits to the Chilean Ministry of Health, in terms of treatment costs averted, by prevention of Haemophilus influenzae type b (HIB) invasive disease, with the costs of adding HIB conjugate vaccine to the diphtheria-tetanus-pertussis (DTP) immunization routinely administered to infants. In their basecase model, over a 10-year period (1991-2000), vaccination against HIB will prevent 1,229 cases of HIB invasive disease, including 713 cases of meningitis, 107 of whom would suffer severe, long-term sequelae, and between 29 and 116 deaths. Assuming a cost of US$1 for a full three-dose regimen of vaccine, the benefit/cost ratio of 1.66, with a net discounted savings of over $403,225, illustrates that HIB vaccine can be cost-beneficial. Sensitivity analyses which alter each of the variables in the analysis indicate that if the true incidence of HIB disease is twice the published rate, then three doses of vaccine remains cost-beneficial at US#3.

PIP: Health practitioners reviewed the clinical records of all 6-60 month old children who were treated for meningitis caused by Haemophilus influenzae type b (HIB) in 1989-1990 at Roberto del Rio Children's Hospital in Santiago, Chile, to estimate costs for all phases of meningitis treatment (ambulatory visits, hospitalization, and follow-up). They also estimated annual HIB incidence. They determined the cost of adding HIB conjugate vaccine to the DTP vaccine. They assumed a cost of US$1 for a full 3-dose regimen of vaccine. They then conducted a cost benefit analysis of the use of HIB conjugate vaccine to prevent invasive HIB disease in Santiago. The National Health Service had to pay an average of US$1301/case of HIB meningitis and US$887/case of HIB invasive disease other than meningitis, including pre- and post-hospitalization costs and adjustment for frequency of sequelae. Several factors indicated that the estimates were actually underestimates. For example, the researchers did not take into account herd immunity and the fact that sequelae often do not appear until the children are older. The addition of the HIB conjugate vaccine to the immunization program would prevent at least 1229-3111 cases of HIB invasive disease, disabling sequelae, and deaths during a 10-year period. Further, it would save the National Health Service more than US$403,225. The benefit/cost ratio was 1.66. The researchers changed each of the variables in the cost benefit analysis. These sensitivity analyses revealed that if the true incidence of HIB disease were 2 times greater than the based on reported data, the 3 doses of HIB conjugate vaccine would still have a cost benefit of US$3. These results indicated that adding HIB conjugate vaccine would exert a considerable public health and cost benefit. Cost benefit analyses of vaccines would also prove useful to decision-makers in other developing countries.