Volume 72 Number 4, 1994
In This Issue:
Paul D. Cleary, Editor
Factors regularly cited as responsible for the faster rise in medical expenditure than in other economic indicators are increased use of medical technology and changes in demographic characteristics, particularly the aging of the population. A number of scholars who have focused on the interaction of these two factors have voiced concern about the necessity and effectiveness of some tertiary care in the United States.
A frequent argument, either stated explicitly or implied, is that the unnecessary use of expensive medical for persons who are close to death is a major contributor to rising medical costs. A well known difficulty with this argument is that it ususally is difficult to predict when a particular patient will die; we do not know which critically ill persons will derive no benefit from a medical intervention. Nevertheless, it is important and useful to assess critically patterns and costs of terminal care.
In this issue, Anne A Scitovsky, one of the country's most knoweledgeable scholars on medical care costs at the end of life, reviews the extensive literature on this topic and concludes that disproportionate use of expensive, high technology medical care at the end of life is not a major factor in rising medical care costs. The data indicate that relatively few elderly patients incur costs that would suggest aggressive, high technology care. She demonstrates as well that reducing hospital care may not result in lowering net expenditures, and she reccomends reevaluating both the physician-patient relationship and our expectation regarding medical care.
A major concern of persons with disabilities is their ability to sustain or regain employment. Edward H. Yelin and Patricia katz provide an insightful analysis of the roles played by general labor market conditions and personal employment history in determining labor market experience of persons with diabilities.
New York state implemented an innovative and comprehensive reform of its psychiatric reimbursement system. In spite of significant professional support for these reforms, its impact on hospital perfomance was limited. Carol A. Boyer and David mechanic analyze the New York experience and assess the factors that they see as necesary for reform to be successful.
A more recent trend in the organization of mental health care has been the "privatization" of certain mental health services. Privatization assumes different meanings according to the context; it frequently refers to states contracting with private community mental health agencies to provide care. Robin E. Clark, Robert A. Dorwart , and Sherie S. Epstein assess the relation between ownership and the management practices and performance of 452 public and private community mental health agencies. They find significant differences in management practices, but not in performance measures such as public orientation and provision of subsidized care.
The Maryland Medicaid program undertook to implement health care system changes in order improve the quality of care for patients in Maryland with diabetes. Among its innovations was increased funding for certain preventive services.
Policy makers regularly must make major programmatic decisions on the best avialable evidence without waiting for rigorous and time consuming evaluation studies. This was the case in Maryland. There was an excellent rationale for each, but it was not possible to evaluate the entire program before it was carried out. The constraints on public programs limited the feasability of launching a large, expensive research study to evaluate this program. Nevertheless, it is from just such innovative, mulitfaceted programs that decision makers can learn the most. In this issue, Mary E. Stuart presents a "policy case study." She describes the rationale for the Maryland program, its implementation process, and, briefly, its known results. Perhaps the most valuable aspect of her analysis, however, is the assessment of the difficulties that crop up when one public payer tries to improve the care in a multipayer system.
