Access to services in the substance abuse treatment system. Variations by facility characteristics.

In view of the importance of type and intensity of services during substance abuse treatment, this chapter looks at treatment and support services that substance abuse clients have access to during treatment. Trends in services over recent years are described. Services available to clients in the current treatment system are reviewed. Several facility characteristics affecting access to services are examined. Different ways of defining access to services are discussed. Findings from the Alcohol and Drug Services Study are used to illustrate service patterns in the national substance abuse treatment system. Variations in service patterns by facility characteristics such as type of care, treatment setting, ownership, percent of facility dependence on public revenue, and level of affiliation are analyzed. The implication is that clients who enter into treatment at different types of facilities are likely to have access to certain types of services.

Managed care for people with disabilities: caring for those with the greatest need.

Disability is discussed in terms of three categories: conditions that result from biomedical conditions and chronic, lifelong illnesses; role or social functioning difficulties that result from behavioral, developmental, or brain disorders; and conditions that limit physical functioning. The range and depth of services needed by the disabled result in higher costs of health care for this population. Because their service needs vary so widely, no single program can address all of the needs equally. Currently, no integrated public policy or program is specifically designed to serve people with disabilities. Rather, they are served by a range of programs that provide specific benefits (e.g., health, social services, and income). Section 1 of this chapter provides an overview on extending the concept of managed care to disabled populations. Special attention is paid to the financing of health care, the delivery of care, reforming the health care system, the cost-containment potential of managed care, and the need to align care with the nature of the individual disability. In sections 2 and 3, the current status of managed care for two special populations--children and the mentally ill--is discussed in greater detail. Section 2 addresses the characteristics of chronically ill and disabled children, public and private health insurance coverage of children with disabilities, other public programs for chronically ill children, and current directions and strategic choices for managed pediatric care. Section 3 describes the mentally ill and the system of providers that currently supplies care to them, offers some conclusions regarding how managed care is changing the policy debate in mental health care, assesses the key factors affecting policy choices in managed care, and considers prospects for the future shape of managed behavioral health care.

Effect of laboratory variation in the prothrombin-time ratio on the results of oral anticoagulant therapy.

BACKGROUND: Patients receiving long-term anticoagulant therapy may be subject to unnecessary risks of bleeding or thromboembolism because of variability in the commercial thromboplastins used to determine prothrombin time and consequent uncertainty about the actual intensity of anticoagulation. METHODS: We explored the effect of this uncertainty on the benefits and risks of anticoagulation in patients with prosthetic heart valves, using models of thromboembolic and hemorrhagic complications as a function of the intensity of anticoagulation, with quality-adjusted life expectancy and average variable costs used to describe outcomes. RESULTS: Anticoagulation provides a striking benefit for patients whose treatment is conducted within the recommended range of the international normalized ratio (INR)--i.e., 2.5 to 3.5--but if uncertainty about the laboratory results causes the intensity of anticoagulation to fall outside this range, the gain becomes smaller. Uncertainty about the true intensity of anticoagulation may reduce the potential gain in life expectancy, adjusted for quality of life, by more than half and may increase the ratio of costs to effectiveness to almost five times the optimal value. Variability in the intensity of anticoagulation is even greater if older recommendations advocating a higher level of anticoagulation are followed. CONCLUSIONS: Uncertainty about the sensitivities of the commercially available thromboplastins used in the United States can have important clinical and economic effects. This problem could be eliminated if clinical laboratories uniformly reported the intensity of anticoagulation as the INR, by adjusting prothrombin-time ratios for variability in thromboplastins.

Anticoagulation for noncardiac procedures in patients with prosthetic heart valves. Does low risk mean high cost?

Hospitalizations for patients with prosthetic heart valves undergoing noncardiac surgery are frequently prolonged for intravenous heparin therapy to decrease the incidence of thromboembolism while patients are not taking oral anticoagulant agents. Because the rate of thromboembolic events is quite low and the period of increased risk is very short, the cost of preventing these rare events can be great. We performed cost-effectiveness analyses addressing these issues. We calculated the marginal cost per additional quality-adjusted year of life gained per thromboembolic event averted and per death averted. We conclude that the marginal cost of prolonging hospitalization to administer heparin is prohibitively high compared with most contemporary therapies, except when the patient has the most thrombogenic of valves. We also discuss the ethical and legal ramifications of integrating the results of cost-effectiveness analyses into clinical practice.