Richard M. Scheffler

Objective The purpose of this paper was to examine the patterns of spending, price, and the utilization of ADHD medications during the 10-year period, from1994 to 2003 among 4 different per capita GDP group countries.

Methods This study used the IMS Health database and included both branded and generic ADHD medications. We examined the changes in quantity and price as well as the mixed effects of these changes in the U.S.A. and 3 other groups of countries classified according to their level of per capita GDP.

Results During this study (1994–2003), the U.S. expenditures for ADHD medications increased 594%; sales volume rose by 80%; and price increased by 285%. In other high GDP countries, expenditures increased 493%, sales volume 328%, and price increased by 39%. In the middle GDP countries, expenditures increased 164%, sales volume 141%, and price increased by 9%. In the countries with a lower per capita GDP, expenditures increased 149%, sales volume 464%, however price decreased by 37%.

Conclusions The launch of long-acting ADHD medications has dramatically increased the total medication expenditure in the U.S. as well as in other high GDP markets. In the other countries quantity was the most important growth factor.

This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. We forecast that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totaling approximately 800,000 health professionals. We estimate the additional annual wage bill required to eliminate the shortage at about $2.6 billion (2007 $US)—more than 2.5 times current wage-bill projections for 2015. We illustrate how changes in workforce mix can reduce this cost, and we discuss policy implications of our results.

We performed a pilot study examining the patterns of recovery from severe mental illness in a model integrated service delivery system using measures from the Milestones of Recovery Scale (MORS), a valid and reliable measure of recovery outcomes which ranges from 1 to 8 (8 levels). For purposes of presentation, we constructed an aggregate MORS (6 levels) where the levels are described as follows: (1) extreme risk; (2) unengaged, poorly selfcoordinating; (3) engaged, poorly self-coordinating; (4) coping and rehabilitating; (5) early recovery, and (6) self reliant. We analyzed MORS data on individuals followed over time from The Village in Long Beach, California (658 observations). Using Markov Chains, we estimated origindestination transition probabilities, simulating recovery outcomes for 100 months. Our models suggest that after 12 months only 8% of ‘‘extreme risk’’ clients remain such. Over 40% have moved to ‘‘engaged, poorly self-coordinating.’’ After 2 years, almost half of the initial ‘‘extreme Risk’’ clients are ‘‘coping/rehabilitating’’, ‘‘early recovery’’ or ‘‘Self reliant.’’ Most gains occur within 2 years.

OBJECTIVE. Approximately 4.4 million (7.8%) children in the United States have been diagnosed with attention-deficit/hyperactivity disorder, and 56% of affected children take prescription medications to treat the disorder. Attention-deficit/hyperactivity disorder is strongly linked with low academic achievement, but the association between medication use and academic achievement in school settings is largely unknown. Our objective was to determine if reported medication use for attentiondeficit/hyperactivity disorder is positively associated with academic achievement during elementary school.

METHOD. To estimate the association between reported medication use and standardized mathematics and reading achievement scores for a US sample of 594 children with attention-deficit/hyperactivity disorder, we used 5 survey waves between kindergarten and fifth grade from the nationally representative Early Childhood Longitudinal Study—Kindergarten Class of 1998 –1999 to estimate a first-differenced regression model, which controlled for time-invariant confounding variables.

RESULTS. Medicated children had a mean mathematics score that was 2.9 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. Children who were medicated for a longer duration (at 2 waves) had a mean reading score that was 5.4 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. The medication-reading association was lower for children who had an individualized education program than for those without such educational accommodation.

CONCLUSIONS. The finding of a positive association between medication use and standardized mathematics and reading test scores is important, given the high prevalence of attention-deficit/hyperactivity disorder and its association with low academic achievement. The 2.9-point mathematics and 5.4-point reading score differences are comparable with score gains of 0.19 and 0.29 school years, respectively, but these gains are insufficient to eliminate the test-score gap between children with attention-deficit/hyperactivity disorder and those without the disorder. Long-term trials are needed to better understand the relationship between medication use and academic achievement.

Objective. To determine whether variation in the representation of minority physicians across geographical areas in California affects the location decisions of minority physicians.

Data Sources. We analyzed data on 9,806 residents and 53,606 patient-care physicians from the 1997–2003 American Medical Association Masterfiles for California along with data from the California Department of Finance, RAND, and other sources.

Study Design. We estimated departure models using linear probability models and destination models using conditional logit. Each model controlled for physician and county characteristics. Parameters of interest include the interactions of physician race/ ethnicity with area-level minority physician representation for the corresponding race/ ethnicity.

Principal Findings. Departure models show that black and Hispanic physicians are more likely to remain in an area as the level of representation of physicians from their respective groups worsens. The destination models show that black, Asian, and Hispanic physicians tend to move to areas where the level of representation is similar to that of their previous location.

Conclusions. Black and Hispanic physicians are influenced by the level of representation of physicians from their respective groups in their location decisions and tend to locate where needed.

In introducing this Special Issue on Social Capital and Health, this article tracks the popularization of the term and sheds light on the controversy surrounding the term and its definitions. It sets out four mechanisms that link social capital with health: making information available to community members, impacting social norms, enhancing the health care services and their accessibility in a community, and offering psychosocial support networks. Approaches to the measurement of social capital include the Social Capital Community Benchmark Survey (SCCBS) developed by Robert Putnam, and the Petris Social Capital Index (PSCI), which looks at community voluntary organizations using public data available for the entire United States. The article defines community social capital (CSC) as the extent and density of trust, cooperation, and associational links and activity within a given population. Four articles on CSC are introduced in two categories: those that address behaviors -- particularly utilization of health services and use of tobacco, alcohol, and drugs; and those that look at links between social capital and physical or mental health. Policy implications include: funding and/or tax subsidies that would support the creation of social capital; laws and regulations; and generation of enthusiasm among communities and leaders to develop social capital. The next steps in the research programme are to continue testing the mechanisms; to look for natural experiments; and to find better public policies to foster social capital.

The world health report 2006: working together for health has brought renewed attention to the global human resources required to produce health.1 It estimated that 57 countries have an absolute shortage of 2.3 million physicians, nurses and midwives. These shortages suggest that many countries have insufficient numbers of health professionals to deliver essential health interventions, such as skilled attendance at birth and immunization programmes. However, these estimates do not take into account the ability of countries to recruit and retain these workers, nor are they specific enough to inform policy-makers about how, and to what extent, health workforce investment should be channelled into training of different professions.

This paper focuses on physicians, who serve a key role in health-care provision. Using the most updated information on the supply of physicians over a 20-year period, we project the size of the future global need for, demand for and supply of physicians to year 2015, the target date for the Millennium Development Goals (MDGs).2 Needs-based estimates use an exogenous health benchmark to judge the adequacy of the number of physicians required to meet MDG targets. Demand estimates are based on a country’s economic growth and the increase in health-care spending that results from it, which primarily goes towards worker salaries. We then compare the needs-based and demand-based estimates to the projected supply of physicians, extrapolated based on historical trends. Our results point to dramatic shortages of physicians in the WHO African Region by 2015. We provide estimates of shortages by country in Africa and discuss their implications for different workforce policy choices.

Social capital has been shown to be associated with reduced mortality due to cardiovascular disease. Our aim was to determine the association of time-varying community-level social capital (CSC) with recurrence of acute coronary syndrome using a retrospective cohort study design. A total of 34,752 men and women were identified, aged 30–85 years, who were hospitalized for acute coronary syndrome between January 1, 1998 and December 31, 2002 in Kaiser Permanente Northern California, USA, an integrated health care delivery system. The primary outcome was recurrent non-fatal or fatal acute coronary syndrome; median follow-up was 19 months. We estimated random-effects, three-level Cox proportional hazard models adjusting for sex, age, race/ethnicity, comorbidities, medication use, and revascularization procedures at level 1, median household income for the census block-group at level 2, and income inequality, racial/ethnic concentration, penetration of health maintenance organizations, and CSC at level 3. Our measure of CSC was the previously validated Petris Social Capital Index (PSCI). We found that a one-standard deviation increase in the PSCI, after adjusting for the above covariates, was significantly associated with decreased recurrence of acute coronary syndrome only for those living in areas where block-group level median household income was below the grand median compared to those living in areas where block-group level median household income was at the grand median or above. These results suggest that community-level social capital may be negatively associated with recurrence of acute coronary syndrome among lower-income individuals.

This paper examines the relationship between area-level social capital and non-specific psychological distress. It demonstrates that not controlling for non-time-varying omitted variables can seriously bias research findings. We use data from three cross-sections of the US National Health Interview Survey (1999, 2000, and 2001): 37,172 observations nested within 58 Metropolitan Statistical Areas. We also add data from the Area Resource File and County Business Patterns. We use a validated measure of social capital, the Petris Social Capital Index (PSCI), which measures structural social capital.

We estimate a two-level multilevel linear model with a random intercept. Non-specific psychological distress is measured using a valid and reliable indicator, the K6. Individual-level variables include sex, age, race/ethnicity, marital status, education, family income, smoking status, exercise status, and number of visits to a health professional. Area-level covariates include the PSCI, the unemployment rate, psychiatrists per 1000 population, non-psychiatric physicians per 1000 population, and area-level indicators to account for non-time-varying area-level omitted variable bias. Time dummies are also included.

We find that lagged area-level social capital is negatively related to non-specific psychological distress among individuals whose family income is less than the median. These associations are much larger when we control for non-time-varying area-level omitted variables.

Little is known about the global use and cost of medications for attention deficit hyperactivity disorder (ADHD). Global use of ADHD medications rose threefold from 1993 through 2003, whereas global spending (2.4 billion US dollars in 2003) rose ninefold, adjusting for inflation. Per capita gross domestic product (GDP) robustly predicted use across countries, but the United States, Canada, and Australia showed significantly higher-than-predicted use. Use and spending grew in both developed and developing countries, but spending growth was concentrated in developed countries, which adopted more costly, long-acting formulations. Promoting optimal prescription and monitoring should be a priority.

BACKGROUND: The authors examined the labor market for registered dental hygienists (RDHs) and dental assistants (DAs) in California from 1997 to 2005 to determine whether there was a shortage in either market.

METHODS: This analysis used economic indicators interpreted within an economic framework to investigate trends in labor force numbers and market-determined wages for RDHs and DAs. Rising inflation-adjusted mean wages indicated a labor shortage, while declining inflation-adjusted mean wages indicated a labor surplus.

RESULTS: From 1999 to 2002, the wages for RDHs increased 48 percent and then stabilized, indicating a shortage had occurred, after which the market achieved equilibrium. Wages for DAs increased 13.9 percent from 1997 to 2001, but then declined from 2001 to 2005, indicating a shortage that then became a surplus. The market for DAs may not have stabilized.

CONCLUSIONS: Wages increased for RDHs and DAs, suggesting that labor shortages occurred in both markets. The large supply response in the market for DAs resulted in wages declining after their initial rise.

PRACTICE IMPLICATIONS: Tracking the local labor markets for RDHs and DAs will enable dental professionals to respond more efficiently to market signals.

We show that the proportion of community social capital attributable to religious groups is inversely and strongly related to the number of cigarettes that smokers consume. We do not find overall community social capital or the proportion of community social capital attributable to religious groups to be related to the overall prevalence of smoking. Using a new validated measure of community social capital, the Petris Social Capital Index and three years (1998-2000) of US data on 39 369 adults, we estimate a two-part demand model incorporating the following controls: community-level fixed effects, price (including excise taxes), family income, a smuggling indicator, nonsmoking regulations, education, marital status, sex, age, and race/ethnicity.

OBJECTIVE: To determine if the market-determined earnings per hour of physicians is sensitive to the degree of area-level racial/ethnic concordance (ALREC) in the local physician labor market.

DATA SOURCES: 1998-1999 and 2000-2001 Community Tracking Study Physician Surveys and Household Surveys, 2000 U.S. Census, and the Area Resource File.

STUDY DESIGN: Population-averaged regression models with area-level fixed effects were used to estimate the determinants of log earnings per hour for physicians in a two-period panel (N=12,886). ALREC for a given racial/ethnic group is measured as the percentage of physicians who are of a given race/ethnicity less the percentage of the population who are of the corresponding race/ethnicity. Relevant control variables were included.

PRINCIPAL FINDINGS: Average earnings per hour for Hispanic and Asian physicians varies with the degree of ALREC that corresponds to a physician's race/ethnicity. Both Hispanic and Asian physicians earn more per hour in areas where corresponding ALREC is negative, other things equal. ALREC varies from negative to positive for all groups. ALREC for Hispanics is negative, on average, due to the small percentage of the physician workforce that is Hispanic. This results in an average 5.6 percent earnings-per-hour premium for Hispanic physicians. However, ALREC for Asians is positive, on average, due to the large percentage of the physician workforce that is Asian. This results in an average 4.0 percent earnings-per-hour discount for Asian physicians. No similar statistically significant results were found for black physicians.

CONCLUSIONS: The market-determined earnings per hour of Hispanic and Asian physicians are sensitive to the degree of ALREC in the local labor market. Larger sample sizes may be needed to find statistically significant results for black physicians.

We analyze Program Realignment, California’s 1991 policy of decentralizing control of health, mental health, and social services, from the state to the counties. Drawing from the economics literature on intergovernmental transfers and using data constructed for this study, we analyze the impact of Realignment on uninsured health spending. We find a change in the pattern of spending on indigent health services by counties following decentralization. Our results suggest, however, that county-level governments maintain a level of commitment to social-service spending that recent studies indicate may be lacking at the state level.

The continued rise in U.S. healthcare spending, along with growth in the number of uninsured, has spurred the move toward consumer-driven health plans. We review new legislation covering such plans, analyze their penetration in the marketplace, and predict their growth. We also use current information about plans that are compatible with Health Savings Accounts to compare them to traditional Preferred Provider Organization plans. Next, we discuss some concerns about the impact of these plans on vulnerable populations, such as the poor and sick. Finally, we suggest how consumer-driven health plans may help to improve the functioning of the healthcare market, especially by producing more transparent information on cost and quality.

This paper empirically examines the role of community social capital in the individual’s health production function. We focus on health measures relating to physical as well as mental health. In addition to exploring the relationship between social capital and health, we test for interrelationships between social and human capital in the production of health. Data come from more than 10 000 adults surveyed in the Indonesian Family Life Surveys of 1993 and 1997. We identify a robust positive empirical association between community-level social capital and good health. We find weak evidence for an interrelationship between human and social capital and mental health.

OBJECTIVE: To assess the impact of changes in relative health maintenance organization (HMO) penetration on changes in the physician-to-population ratio in California counties when changes in the economic conditions in California counties relative to the U.S. average are taken into account.

DATA SOURCES: Data on physicians who practiced in California at any time from 1988 to 1998 were obtained from the AMA Masterfile. The analysis was restricted to active, patient care physicians, excluding medical residents. Data on other covariates in the model were obtained from the Bureau of Economic Analysis, InterStudy, the Area Resource File, and the California state government. Data were merged using county FIPS codes.

STUDY DESIGN: Changes in the physician-to-population ratio in California counties include the effects of both intrastate migration and interstate migration. A reduced-form model was estimated using the Arellano-Bond dynamic panel estimator. Economic conditions in California relative to the U.S. were measured as the ratio of county-level real per capita income to national-level real per capita income. Relative HMO penetration in California was measured as the ratio of county-level HMO penetration to HMO penetration in the U.S. relative HMO penetration was instrumented using five identifying variables to address potential endogeneity. Omitted-variable bias was controlled for by first differencing the model. The model also incorporated eight other covariates that may be associated with the demand for physicians: the percentage of the population enrolled in Medicaid, beds in short-term hospitals per 100,000 population, the percentage of the population that is black, the percentage of the population that is Hispanic, the percentage of the population that is Asian, the percentage of the population that is below age 18, the percentage of the population that is aged 65 and older, and the percentage of the population that are new legal immigrants in a given year. All of the above variables were lagged one period. The lagged physician-to-population ratio was also included to control for the supply of physicians. Separate equations were estimated for primary care physicians and specialist physicians.

PRINCIPAL FINDINGS: Changes in lagged relative HMO penetration are negatively associated with changes in specialist physicians per 100,000 population. However, this effect of HMO penetration is attenuated and at times reversed in areas where the magnitude of the difference in relative economic conditions is sufficiently large. We did not find any statistically significant effects for primary care physicians.

CONCLUSIONS: Consistent with prior studies, we find that changes in physician supply are associated with changes in relative HMO penetration. Relative economic conditions are an important moderator of the effect of changes in relative HMO penetration on physician migration.

The authors discuss the changing role of the antitrust policy in today’s health care markets and possible future environments. The antitrust challenges today lie in maintaining competition when hospitals merge or bargain as multi-hospital systems, providing access in areas with high concentration of hospital closures, incorporating quality into the measures of market power. The role of quality competition may become more important in the future scenarios such as single payer system under fixed prices.

A joint Wharton School-World Bank conference called attention to the high proportions of medical care spending paid out of pocket in most developing countries. One of the reasons for this, attendees said, is the problem in such economies of generating high tax revenues in a nondistortive way. Since people are paying out of pocket, they should be able to afford some private insurance that can spread the risk of above-average out-of-pocket payments. The potential efficiency gains from greater use of voluntary private insurance seem large, but there are a number of possible impediments to the emergence of such insurance.

Hospitals face serious financial challenges in the current healthcare marketplace. In response to these challenges, they may alter their service offerings, eliminating services that are perceived as money-losing or adding new services in areas where profitability is expected to be greater. Although research has examined hospital closures, the more subtle phenomenon of hospital service changes has not been systematically studied. This issue is important because different types of hospital service changes could have different effects on hospital financial viability: extensive service closures could contribute to a downward spiral leading to hospital closure, whereas adding new services might help improve a hospital's finances. This article' examines changes in hospital service availability in California general acute care hospitals between 1995 and 2002. Our major findings indicate that many California hospitals made changes in their service offerings during the study period, although few made extensive changes. Altogether, about half of the hospitals in our study population either closed or opened at least one service. Nearly one-fourth of the hospitals in our study population closed one or more services, whereas just under one-third opened one or more new services. However, the vast majority of the hospitals that closed or added a service made only one or two such changes. In addition, few hospitals both closed and opened services. The service closed most frequently was normal newborn labor and delivery (obstetrics), whereas inpatient rehabilitation was the most frequently opened service. Hospitals that made the most service changes tended to be small, rural, and financially troubled at the start of the study period. Among this group of hospitals, service closures were associated with continued financial deterioration, whereas new service openings were associated with improvements in key financial ratios.

BACKGROUND: Previous studies have documented sex and racial/ethnic disparities in outcomes after acute myocardial infarction (AMI), but the explanation of these disparities remains limited. In a setting that controls for access to medical care, we evaluated whether sex and racial/ethnic disparities in prognosis after AMI persist after consideration of socioeconomic background, personal medical history, and medical management.

METHODS: We conducted a prospective cohort study of the members (20,263 men and 10,061 women) of an integrated health care delivery system in northern California who had experienced an AMI between January 1, 1995, and December 31, 2002, and were followed up for a median of 3.5 years (maximum, 8 years). Main outcome measures included AMI recurrence and all-cause mortality.

RESULTS:  In age-adjusted analyses relative to white men, black men (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.26-1.65), black women (HR, 1.47; 95% CI, 1.26-1.72), and Asian women (HR, 1.37; 95% CI, 1.13-1.65) were at increased risk of AMI recurrence. However, multivariate adjustment for sociodemographic background, comorbidities, medication use, angiography, and revascularization procedures effectively removed the excess risk of AMI recurrence in these 3 groups. Similarly, the increased age-adjusted risk of all-cause mortality seen in black men (HR, 1.55; 95% CI, 1.37-1.75) and black women (HR, 1.45; 95% CI, 1.27-1.66) was greatly attenuated in black men and reversed in black women after full multivariate adjustment.

CONCLUSION: In a population with equal access to medical care, comprehensive consideration of social, personal, and medical factors could explain sex and racial/ethnic disparities in prognosis after AMI.

Recent surveys among psychologists and historical accounts of the profession document important practice pattern differences among psychologists on the basis of years of postlicensure experience. Evidence for these differences across 4 groups of psychologists was examined from responses to the 2000 California Survey of Psychological Practice. Psychologists with fewer than 5 years of experience were found to treat on a weekly basis a greater percentage of patients with childhood disorders and substance abuse disorders and to spend a greater percentage of practice time in public health and/or mental health settings than other psychologists. No differences were found in the use of 3 dominant forms of psychotherapy. The implications of these results for practicing psychologists, graduate faculty and students, and representatives of state psychological associations are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

This paper reviews the current status of the global pharmaceutical industry and its research and development focus in the context of the health care needs of the developing world. It will consider the attempts to improve access to critical drugs and vaccines, and increase the research effort directed at key public health priorities in the developing world. In particular, it will consider prospects for public-private collaboration. The challenges and opportunities in such public-private partnerships will be discussed briefly along with a look at factors that may be key to success. Much of the focus is on HIV/AIDS where the debate on the optimal balance between intellectual property rights (IPR) and human rights to life and health has been very public and emotive.

In November 2004 California passed Proposition 63, a landmark piece of mental health and fiscal legislation. This initiative places a 1 percent tax on adjusted gross income over $1 million, affecting about 30,000 taxpayers and raising $1.8 billion (a 31 percent increase) in new revenues over the first three years to support county-operated mental health systems. Our analysis suggests that Proposition 63 passed with strong support from Democrats, urban dwellers, and social workers and in counties with high rates of homelessness. Proposition 63 faces challenges in implementation and provides unprecedented opportunities for transformation and change.

OBJECTIVE: To provide a national profile of the area variation in per-capita psychostimulant consumption in the U.S.

METHODS: We separated 3030 U.S. counties into two categories of 'low' and 'high' per-capita use of attention deficit hyperactivity disorder (ADHD) drugs (based on data from the Drug Enforcement Administration), and then analyzed them on the basis of their socio-demographic, economic, educational and medical characteristics.

RESULTS: We found significant differences and similarities in the profile of counties in the U.S. that are above and below the national median rate of per-capita psychostimulant use (defined as g/per 100K population). Compared to counties below the median level, counties above the median level have: significantly greater population, higher per-capita income, lower unemployment rates, greater HMO penetration, more physicians per capita, a higher ratio of young-to-old physicians and a slightly higher students-to-teacher ratio.

CONCLUSIONS: Our analysis of the DEA's ARCOS data shows that most of the significant variables correlated with 'higher' per-capita use of ADHD drugs serve as a proxy for county affluence. To provide a more complex, multivariate analysis of the area variation in psychostimulant use across the U.S.-which is the logical next step-requires obtaining price data to match the DEA's quantity data.

This article assesses how the institutional context of decision making on three-judge panels of the federal Court of Appeals affects the impact that gender and race have on judicial decisions. Our central question is whether and how racial minority and women judges influence legal policy on issues thought to be of particular concern to women and minorities when serving on appellate panels which decide cases by majority rule. Proper analysis of this question requires investigating whether women and minority judges influence the decisions of other panel members. We find that the norm of unanimity on panels grants women influence over outcomes even when they are outnumbered on a panel.

The mental health workforce has changed dramatically since the mid-1970s. Nonphysician providers, particularly psychologists and clinical social workers, have become a much larger share of the workforce. While the supply of psychiatrists has been relatively stable, there has been a dramatic increase in the supply of psychologists and social workers. Changes in clinical practice, combined with the continued expansion of managed care into mental health, will largely determine the future composition and supply of the mental health workforce.

This paper reviews the current status of the global pharmaceutical industry and its research and development focus in the context of the health care needs of the developing world. It will consider the attempts to improve access to critical drugs and vaccines, and increase the research effort directed at key public health priorities in the developing world. In particular, it will consider prospects for public-private collaboration. The challenges and opportunities in such public-private partnerships will be discussed briefly along with a look at factors that may be key to success. Much of the focus is on HIV/AIDS where the debate on the optimal balance between intellectual property rights (IPR) and human rights to life and health has been very public and emotive.

This paper addresses market failure due to externalities, as well as information asymmetries and public policy problems that need to be solved to ensure high quality care for affective disorders. We delineate the problems in parity legislation, managed care, as well as Medicare and Medicaid that need to be addressed to reduce the burden of illness affective disorders. A research agenda is developed for formulating and implementing public policy.

Thirty-four states have enacte mental health parity laws that require a health plan, insurer, or employer to provide coverage for mental illness equal to that for physical illness. This study analyzed definitions of mental illness used in state parity laws, identified factors influencing the development of these definitions, and examined the effects of different definitions on access to care for persons with mental illness.

METHODS: Specific language in each state's parity legislation was analyzed. Interviews were conducted with policy makers, mental health providers, advocates, and insurers to determine factors influencing a state's definition. Current definitions of mental illness used in the clinical literature and in federal policy were reviewed and compared with definitions used in state parity laws.

RESULTS: The definitions of mental illness used in state parity legislation vary significantly and fall into one of three major categories: "broad-based mental illness," "serious mental illness," or "biologically based mental illness." To define each of these categories, state legislatures do not rely on clinically accepted definitions or federal mental health policy. Rather, influenced by political and economic factors, they are developing their own definitions.

CONCLUSIONS: Definitions of mental illness in state parity laws have important implications for access, cost, and reimbursement; they determine which populations receive a higher level of mental health services. Future research must qualitatively examine how state definitions affect the use and cost of mental health services.

This study was conducted to examine the association between psychiatrists' demographic characteristics, payment source, and managed care participation and psychiatrists' practice workload, and between the supply of other mental health providers in a psychiatrist's county of practice and psychiatrists' practice workload. Data from the 1996 American Psychiatric Association National Survey of Psychiatric Practice were merged with national countywide measures of mental health workforce and environmental data from the 1996 Area Resource File. In comparison to male psychiatrists, female psychiatrists treat fewer patients per week, provide less total hours of weekly patient care, and obtain fewer new monthly referrals. An increase in psychiatrists' managed care participation was associated with only minor increases in the number of patients per week, weekly time spent in clinical care, and number of new monthly referrals. The supply of other mental health providers was not associated with variation in practice workload. Once psychiatrists participate in managed care plans, an increase in their participation rate does not significantly expand clinical practice workload. The supply of other mental health providers was not significantly associated with variation in psychiatrists' workload, which suggests that substitution effects may not be evident with this aspect of psychiatric practice.

OBJECTIVE:  The authors compared data from psychiatrists and psychologists in California to determine whether long-standing differences in clinical practice remain after the introduction of managed care and other changes in mental service delivery.

METHODS: Responses from practicing clinicians in California who participated in the 1998 National Survey of Psychiatric Practice and the 2000 California Survey of Psychological Practice were compared on items related to patient caseload, practice profile, and insurance or reimbursement arrangements.

RESULTS: Data from 97 psychiatrists and 395 psychologists were available for the study. Psychiatrists reported spending more hours on most aspects of practice and working more total hours per week than psychologists. The weekly caseloads reported by psychiatrists included a greater percentage of persons treated for psychotic conditions than did the caseloads of psychologists. Psychologists reported that their weekly caseloads included a greater percentage of persons treated for anxiety disorders, personality disorders, and other disorders. Psychiatrists reported receiving a greater average payment for services from public insurance, and psychologists reported treating a greater average percentage of patients who did not have insurance coverage. Significant differences in income sources and fee arrangements were observed, and the net reported income of psychiatrists was nearly 80 percent greater than that of psychologists.

CONCLUSIONS: Long-standing differences in clinical practice patterns remain between psychiatrists and psychologists despite managed care staffing arrangements and treatment strategies that streamline the practices of both provider groups. The significant income and wage differences between psychiatrists and psychologists may be partly due to supply dynamics of the mental health workforce that adversely affect psychologists.

OBJECTIVE: The authors compared data from psychiatrists and psychologists in California to determine whether long-standing differences in clinical practice remain after the introduction of managed care and other changes in mental service delivery.

METHODS: Responses from practicing clinicians in California who participated in the 1998 National Survey of Psychiatric Practice and the 2000 California Survey of Psychological Practice were compared on items related to patient caseload, practice profile, and insurance or reimbursement arrangements.

RESULTS: Data from 97 psychiatrists and 395 psychologists were available for the study. Psychiatrists reported spending more hours on most aspects of practice and working more total hours per week than psychologists. The weekly caseloads reported by psychiatrists included a greater percentage of persons treated for psychotic conditions than did the caseloads of psychologists. Psychologists reported that their weekly caseloads included a greater percentage of persons treated for anxiety disorders, personality disorders, and other disorders. Psychiatrists reported receiving a greater average payment for services from public insurance, and psychologists reported treating a greater average percentage of patients who did not have insurance coverage. Significant differences in income sources and fee arrangements were observed, and the net reported income of psychiatrists was nearly 80 percent greater than that of psychologists.

CONCLUSIONS: Long-standing differences in clinical practice patterns remain between psychiatrists and psychologists despite managed care staffing arrangements and treatment strategies that streamline the practices of both provider groups. The significant income and wage differences between psychiatrists and psychologists may be partly due to supply dynamics of the mental health workforce that adversely affect psychologists.

To examine service cost and access for persons with severe mental illness under Medicaid mental health capitation payment in Colorado. Capitation contracts were made with two organizational models: community mental health centers (CMHCs) that manage and deliver services (direct capitation [DC]) and joint ventures between CMHCs and a for-profit managed care firm (managed behavioral health organization, [MBHO]) and compared to fee for service (F.F.S.).

Affective disorders impose a substantial individual and societal burden. Despite availability of efficacious treatments and practice guidelines, unmet need remains high. To reduce unmet need and the burden of affective disorders, information is needed on the distribution of burden across stakeholders, on barriers to reducing burden, and on interventions that effectively reduce burden at the levels of practice, community, and policy. This article provides the report of the Working Group on Overcoming Barriers to Reducing the Burden of Affective Disorders, for the National Institute of Mental Health Strategic Plan on Mood Disorders. We review the literature, identify key gaps, and recommend new research to guide national efforts to reduce the burden of affective disorders.

This study examined whether decentralization of California's public mental health system under program realignment has changed the composition of the client population, with greater attention toward inclusion of persons with a severe mental illness. Clients' demographic and clinical status were compared before and after realignment. The study sample consisted of 75,951 clients, representing 1.5 million adults who accessed the public mental health services in California during a 6-year study period. The post-realignment client population had lower functional status, more unemployment, and lower levels of education-all indicating greater functional impairment. They were more likely to suffer from an affective disorder, but they were less likely to have either a non-psychotic disorder or schizophrenia. The study found no evidence suggesting that realignment jeopardized access to the public mental health system in California, and it indicated at least the possibility that it promoted greater access by clients with greater functional impairment.

Decentralization of California's public mental health system under program realignment has changed the utilization and cost of community-based mental health services. This study examined a sample of 75,951 users, representing 1.5 million adults who visited California's public mental health services during a 6-year period (FY 1988-1990 and FY 1992-1994). Regression analysis was performed to examine cost and utilization reduction over time, across regions, and across psychiatric diagnoses. Overall utilization and cost of community-based mental health services dropped significantly after the implementation of realignment. They were significantly lower for (a) 24-hour services in the urban industrialized Southern Region and (b) outpatient services in the agricultural Central Region of the state. Users diagnosed with mood disorders took a greater portion, but were associated with significantly less treatment and cost than other users in the post-realignment period. When local communities bear the financial risks and rewards, they find more efficient methods of delivering community-based mental health services.

The California Survey of Psychological Practice provides comprehensive data on patient case mix, treatments, practice settings, and payment sources using a representative sample of psychologists. These psychologists practice in diverse settings and continue to deliver traditional psychotherapies. California psychologists' treatment of persons with private insurance highlights the profession's public health contribution by improving the functioning of employed persons and their families. Despite high managed care enrollment among Californians, these psychologists demonstrate wide variability in managed care participation. The authors compare the findings to prior surveys among psychologists and discuss the findings in relation to trends in psychological practice and public policy.

Data from the 2000 Calffornia Survey of Psychological Practice (D. Pingitore, R. Scheffler, M. Haley, T. Sentell, & D. Schwalm, 2001) were used to measure psychologists' income variation associated with demographic characteristics, managed care participation rate, and mental health workforce supply concentrations. A 10% increase in the supply of psychologists in a psychologists' market of practice resulted in a $1,749 reduction in income compared with a $1,330 income reduction due to a 10% increase in managed care participation. The authors discuss how psychologists' income and other aspects of practice are shaped by market dynamics, trends in the psychologist workforce, and public policy.

Income, an important facet of professional psychological practice, differs by gender. The potential sources of income differences among California clinical psychologists were investigated. Full-time female psychologists earned significantly less income on average than full-time male psychologists, despite similar patient demographics, caseloads, practice profiles, and payment sources. In separate regression models, professional experience increased income more for men than for women, whereas greater psychologist supply decreased income for both groups. According to the regression model, if female psychologists were paid like male psychologists, they would receive, on average

The 1996 Mental Health Parity Act (MHPA), which became effective in January 1998, is scheduled to expire in September 2001. This paper examines what the MHPA accomplished and steps toward more comprehensive parity. We explain the strategic and self-reinforcing link of parity with managed behavioral health care and conclude that the current path will be difficult to reverse. The paper ends with a discussion of what might be behind the claims that full parity in mental health benefits is insufficient to achieve true equity and whether additional steps beyond full parity appear realistic or even desirable.

The 1996 Mental Health Parity Act (MHPA), which became effective in January 1998, is scheduled to expire in September 2001. This article provides an overview of what the MHPA intended to do and what it actually has accomplished. We summarize state legislature actions through the end of 2000 and report on their effects on employer-sponsored mental health coverage using a national survey fielded in 1999-2000. We then discuss possible amendments to the MHPA and reforms beyond full parity that might be considered.

This paper identifies the impact of "program realignment," a 1991 California state policy that significantly enhanced local governments' financial risk and programmatic authority for public mental health services, on treatment costs per user, and on the mix of inpatient and outpatient service costs. The study employs a natural pre-realignment and post-realignment design using the 59 California local mental health authorities (LMHAs) as the unit of analysis over a seven-year period spanning policy implementation. Total treatment and inpatient cost per user decreases and outpatient cost per user increases after program realignment. Higher levels of contracting with private providers tend to enhance this trend, while risk for institutional services reduces user costs uniformly. Financial and programmatic decentralization can enhance cost efficiency in treatment, while promoting substitution of outpatient services for inpatient services. Local conditions such as risk and contracting determine the extent of the policy response.

This article describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.

Using national data and the most recent OECD figures, we provide an updated assessment of the Spanish health care system and its reforms. We compare figures from Spain with other major industrialized nations and find that the Spanish system appears macro-economically efficient and equitable. However, like many other countries in Europe and elsewhere, the Spanish health care system confronts continued pressures to provide high-quality universal care in the face of ever increasing costs and competing uses for financial resources. These pressures have prompted the enactment of several reforms, which are reviewed. We draw from the American experience with managed care and managed competition to illustrate possible paths for further reform.