Effects of a high-complex-carbohydrate, low-fat, low-cholesterol diet on levels of serum lipids and estradiol.

Recent studies have implicated elevated levels of serum estradiol in males as the major predisposing factor for myocardial infarction, with serum cholesterol playing a secondary role. The purpose of the present study was to investigate the effects of a high-complex-carbohydrate, low-fat, low-cholesterol diet and daily exercise on levels of serum estradiol, testosterone, and lipids in males. Twenty-one males participating in the Pritikin Longevity Center 26-day residential program volunteered for the study. During the program, serum estradiol levels were significantly reduced from 47.2 +/- 4.6 to 23.8 +/- 2.5 pg/ml (mean +/- SE) whereas serum testosterone levels were unchanged (5.1 +/- 0.3 versus 5.1 +/- 0.2 ng/ml). Total serum cholesterol levels were reduced from 229 +/- 9 to 181 +/- 7 mg/dl whereas triglyceride levels were reduced from 301 +/- 66 to 151 +/- 13 mg/dl. High-density lipoprotein-cholesterol levels fell from 41 +/- 3 to 35 +/- 1 mg/dl whereas the ratio of total cholesterol to high-density lipoprotein-cholesterol was unchanged (5.5 +/- 0.4 versus 5.1 +/- 0.3).

Risk sharing in managed behavioral health care.

While policymakers have expressed concern over the impact of risk sharing with providers on treatment patterns, the literature lacks decisive evidence on which to base policy. This paper evaluates the impact of a contracting change within a managed behavioral health organization from a fee-for-service system to a case-rate system with utilization management delegated to providers. The contracting change resulted in a 25 percent reduction in mental health visits per episode. This effect varies with the dollar amount of the case rate and is more pronounced for providers with a larger share of revenue from risk contracts and with intensive utilization management programs.

Managed care and market power: physician organizations in four markets.

Physicians and other providers have responded to the spread of managed care by adapting structures and strategies to accommodate or resist the pressures exerted on them to reduce costs. In this paper we examine how physician organizations have evolved in four markets and whether their features represent attempts to improve efficiency or resist change. The strategies adopted by physicians in terms of alignment with other providers and development of independent medical management capabilities appear to be sensitive to opportunities to reap cost savings and the competitiveness of physician, hospital, and health plan markets.

The Medicare prescription drug benefit: how will the game be played?

Most recent proposals to add a prescription drug benefit to the Medicare program suggest using pharmacy benefit managers (PBMs) to control costs and promote quality. However, the proposals give little detail on the institutional arrangements that would govern PBM operations and drug procurement. The recent Congressional Budget Office cost estimate of the Clinton administration's proposal reflects this lack of detail on how PBMs would function. We sketch an approach for structuring PBM operations that focuses on competition among PBMs, manufacturers, and distributors; incentive pricing; and risk sharing with PBMs.

Scale and structure of capitated physician organizations in California.

Physician organizations in California broke new ground in the 1980s by accepting capitated contracts and taking on utilization management functions. In this paper we present new data that document the scale, structure, and vertical affiliations of physician organizations that accept capitation in California. We provide information on capitated enrollment, the share of revenue derived by physician organizations from capitation contracts, and the scope of risk sharing with health maintenance organizations (HMOs). Capitation contracts and risk sharing dominate payment arrangements with HMOs. Physician organizations appear to have responded to capitation by affiliating with hospitals and management companies, adopting hybrid organizational structures, and consolidating into larger entities.

Risk sharing and the supply of mental health services.

This paper examines the effects of risk sharing with mental health providers in a managed care context. The results show that providers that received a fixed payment per case reduced the number of outpatient visits by 20-25%, compared with providers who continued to be paid for each visit. This effect was stronger for integrated group practices and providers with more intensive utilization review protocols. In addition, evidence was found that in a setting where providers serve multiple payers, the share of their total revenue derived from risk-sharing contracts is an important determinant of the magnitude of the supply response.

Health plans and selection: formal risk adjustment vs. market design and contracts.

In this paper, we explore the demand for risk adjustment by health plans that contract with private employers by considering the conditions under which plans might value risk adjustment. Three factors reduce the value of risk adjustment from the plans' point of view. First, only a relatively small segment of privately insured Americans face a choice of competing health plans. Second, health plans share much of their insurance risk with payers, providers, and reinsurers. Third, de facto experience rating that occurs during the premium negotiation process and management of coverage appear to substitute for risk adjustment. While the current environment has not generated much demand for risk adjustment, we reflect on its future potential.

Psychological aspects of menopause.

There are no psychological symptoms specific to menopause, though minor psychological complaints such as irritability may increase in women aged 45 to 55. These symptoms seem to be related to psychosocial stress, social class, or cultural group rather than to hormone imbalance alone. Management requires careful assessment of the medical as well as the psychosocial situation.

Infertility: psychotherapeutic issues.

In supportive therapy with infertility patients, the clinician tries to relieve dysphoria and enhance self-esteem. Dynamically informed supportive interventions are designed to decrease guilt that may relate to past sexual activities, sexually related diseases, or abortions. These interventions should also be empathetic, promote optimism and reality testing, help with problem solving, allow catharsis and ventilation, decrease feelings of isolation and loneliness, educate and clarify, and praise and encourage where appropriate. Mental health clinicians have an important role to play in the treatment of these patients, provided they learn enough about the psychology of the experience of infertility and about the technology utilized in its treatment. As the number of people seeking treatment for infertility grows, the need for skilled therapists for this population will grow at a parallel rate.

Helping women help themselves: developing a menopause discussion group.

Menopause discussion groups are needed to provide women with accurate and up-to-date information, but--more importantly--to facilitate sharing experiences, to help women understand their choices, and to empower them to be informed and take care of themselves. Members of a group who are comfortable expressing their feelings and thoughts find a therapeutic benefit from group participation. Health care providers are urged to develop these groups in their communities to assist women as they approach menopause and beyond.

Primary and secondary hypothyroidism in nasopharyngeal carcinoma.

We investigated the thyroid and pituitary functions of six of the seven patients with nasopharyngeal carcinoma who had been previously treated with external radiation, and who were seen at the San Francisco Veterans Administration Hospital within a recent 18 month period. Two patients had primary hypothyroidism, and four had secondary hypothyroidism. These findings suggest that thyroid and pituitary abnormalities are frequent complications of both nasopharyngeal carcinoma and its treatment.

A sexuality curriculum for gynecology residents.

PIP: A research project was conducted with the obstetrics and gynecology residents at University Hospitals of Cleveland in February 1976. The purpose was to provide residents with basic knowledge about female sexual problems, to assess the residents' skill and comfort in interviewing patients with sexual problems, to document the effects of supervision on interviewing skills, and to evolve a sexuality curriculum for residents in obstetrics and gynecology. 13 residents at various stages of training participated. The project's 5-1/2 hours were distributed over 2-1/2 weeks. 4 women were taught to respond as if they were patients with the following specific complaints: failure to develop sexual responsiveness, loss of responsiveness due to anger, loss of libido due to depression, and frustration becuase of an impotent husband. The sequence of activities was 1) required reading of a 2-page protocol for assessing a sexual complaint; 2) completion of a preinterview questionnaire which assessed comfort and skill measured on a 5-point scale, immediately followed by a 20-minute videotaped interview with the 1st patient; 3) reading of an article on female sexual dysfunction; 4) attendance at a 2-hour lecture on female sexual dysfunction and interviewing techniques; and 5) conduct of a 2nd, 3rd, and 4th interview over a 2-week period. Each interview was followed by a 45-minute session with the supervisor to view and discuss the videotape. As a group the residents' interviewing abilities failed to improve by the end of the program, as measured by total percentage of programmed content elicited; method of obtaining information, that is, direct or indirect questions; and style ratings. Recommendations are made concerning the educational needs of residents in obstetrics and gynecology.^ieng