Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.     

Transforming the Safety Net: Responses to Medicaid Managed Care in, Rural and Urban New Mexico

In this article we examine the impact of Medicaid managed care on safety net organizations in New Mexico and their ability to maintain their traditional mission of charity care. We address two particular areas of concern that have arisen in the literature on Medicaid managed care. First, analysts have debated under what circumstances safety net organizations are better positioned to survive under market competition without abandoning their social orientation. Second, analysts have suggested that populations in rural areas may be more disadvantaged under Medicaid managed care due to its intensification of already-existent barriers to access. By comparing the differential ability of safety net organizations in rural and urban New Mexico to buffer their patients from potentially harmful effects of Medicaid managed care, we identify factors that place these safety nets particularly at risk. We find that a rural location, lack of affiliation with a larger organization, and lack of recourse to charitable funding are "risk factors" determining who sinks—and who floats—in this new competitive health care system, [privatization of health care, Medicaid safety net organizations, managed care, resistance, ruralurban]     

Providers and staff respond to Medicaid managed care: the unintended consequences of reform in New Mexico

In 1997 a new Medicaid managed care (MMC) program called Salud! was implemented by the State of New Mexico. This article serves as an introduction to a special issue of Medical Anthropology Quarterly that assesses the unintended consequences of this reform and its impact on providers and staff who work in clinics, physician offices, and emergency rooms where Medicaid patients are served. MMC fused state and corporate bureaucracies, creating a complex system where enrollment and access was difficult. The special issue focuses on providers' responses to these new structures, including ways in which staff buffer the impact of reform and the role of the discourses of medical necessity and accountability in shaping the way in which MMC functions.     

Confronting utilization review in New Mexico's Medicaid mental health system: the critical role of "medical necessity"

The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.     

Deadly inequality in the health care "safety net": uninsured ethnic minorities' struggle to live with life-threatening illnesses

Forty-three million Americans are uninsured. This article explores the difficulties people experience in seeking health care through the health care "safety net," which provides most of the health care that uninsured people receive, and critiques the gaps, inconsistencies, and failures of such care. In research with 176 African Americans and Latinos who had no health insurance, it was found that they delay seeking care because of cost, do without medications, have negative views of safety net health care, and experience discrimination. As a consequence of dissatisfaction with safety net care, avoidance of the health care system was commonplace. It is concluded that safety net health care facilitates the development of unhealthy practices, such as delays in seeking care. The inadequacy of safety net health care is thus injurious to people's health.     

De facto disentitlement in an information economy: enrollment issues in Medicaid managed care

This article discusses enrollment issues in New Mexico's Medicaid managed care (MMC) system and seeks to illuminate reasons for persistent problems reported by workers and clients. It argues that between 1997 and 2000, the MMC and welfare reforms raised enrollment barriers by complicating and dehumanizing the system, thus "technically disenfranchising" workers and clients. Specifically, the new system increased the need for professional, in-person enrollment assistance precisely when the state decreased its provision of it. Some aspects of the State Child Health Insurance Program (SCHIP) reforms indirectly aggravated those same problems, and though they also significantly lowered barriers in some areas, overall the new system was plagued with preexisting barriers as well as new, unmet needs that produced "de facto disentitlement" to health services.     

Different subjects: the health care system's participation in the differential construction of the cultural citizenship of Cuban refugees and Mexican immigrants

This paper explores the public health system's differential construction of Mexican and Cuban immigrants' "deservingness" of citizenship benefits and its preparation of them for different roles in U.S. society. Civic institutions such as the public health care system are charged with inculcating normative behavior in immigrants and instilling in them different conceptions about their rights and responsibilities. Faced with limited resources under the implementation of Medicaid managed care, hospital administrators created new categories of "deserving" and "undeserving" immigrants based on neoliberal standards of individual responsibility and self-discipline. As a result, hospital policies construct different types of "cultural citizenship" for Cuban and Mexican immigrants, preparing the former to be active citizens and discouraging the latter from pressing demands on American civil institutions. I show that this negative construction of Mexican immigrants' moral worth leads to unmet health needs and poor health outcomes.     

National Use of Safety-Net Clinics for Primary Care among Adults with Non-Medicaid Insurance in the United States

Objective

To describe the prevalence, characteristics, and predictors of safety-net use for primary care among non-Medicaid insured adults (i.e., those with private insurance or Medicare).

Methods

Cross-sectional analysis using the 2006–2010 National Ambulatory Medical Care Surveys, annual probability samples of outpatient visits in the U.S. We estimated national prevalence of safety-net visits using weighted percentages to account for the complex survey design. We conducted bivariate and multivariate logistic regression analyses to examine characteristics associated with safety-net clinic use.

Results

More than one-third (35.0%) of all primary care safety-net clinic visits were among adults with non-Medicaid primary insurance, representing 6,642,000 annual visits nationally. The strongest predictors of safety-net use among non-Medicaid insured adults were: being from a high-poverty neighborhood (AOR 9.53, 95% CI 4.65–19.53), being dually eligible for Medicare and Medicaid (AOR 2.13, 95% CI 1.38–3.30), and being black (AOR 1.97, 95% CI 1.06–3.66) or Hispanic (AOR 2.28, 95% CI 1.32–3.93). Compared to non-safety-net users, non-Medicaid insured adults who used safety-net clinics had a higher prevalence of diabetes (23.5% vs. 15.0%, p<0.001), hypertension (49.4% vs. 36.0%, p<0.001), multimorbidity (≥2 chronic conditions; 53.5% vs. 40.9%, p<0.001) and polypharmacy (≥4 medications; 48.8% vs. 34.0%, p<0.001). Nearly one-third (28.9%) of Medicare beneficiaries in the safety-net were dual eligibles, compared to only 6.8% of Medicare beneficiaries in non-safety-net clinics (p<0.001).

Conclusions

Safety net clinics are important primary care delivery sites for non-Medicaid insured minority and low-income populations with a high burden of chronic illness. The critical role of safety-net clinics in care delivery is likely to persist despite expanded insurance coverage under the Affordable Care Act.     

The politics of recognition in culturally appropriate care

Over the last 20 years, the concept of culturally appropriate health care has been gradually gaining popularity in medicine and public health. In calling for health care that is culturally appropriate, minority groups seek political recognition of often racialized constructions of cultural difference as they intervene in health care planning and organization. Based on interview narratives from people involved in community organizing to establish a federally funded community health center in a mid-size New England city, I chart the emergence of a language of "culturally appropriate health care" in language used to justify the need for a health center. An identity model of recognition underlies the call for ethnic resemblance between patient and provider seen in many culturally appropriate care programs. I contrast this model of health care with earlier calls for community access and control by activists in the 1970s and explore the practical and theoretical implications of each approach.     

Racial differences in colorectal cancer survival at a safety net hospital

BackgroundWhile racial disparity in colorectal cancer survival have previously been studied, whether this disparity exists in patients with metastatic colorectal cancer receiving care at safety net hospitals (and therefore of similar socioeconomic status) is poorly understood.MethodsWe examined racial differences in survival in a cohort of patients with stage IV colorectal cancer treated at the largest safety net hospital in the New England region, which serves a population with a majority (65%) of non-Caucasian patients. Data was extracted from the hospital’s electronic medical record. Survival differences among different racial and ethnic groups were examined graphically using Kaplan-Meier analysis. A univariate cox proportional hazards model and a multivariable adjusted model were generated.ResultsBlack patients had significantly lower overall survival compared to White patients, with median overall survival of 1.9 years and 2.5 years respectively. In a multivariate analysis, Black race posed a significant hazard (HR 1.70, CI 1.01–2.90, p = 0.0467) for death. Though response to therapy emerged as a strong predictor of survival (HR = 0.4, CI = 0.2-0.7, p = 0.0021), it was comparable between Blacks and Whites.ConclusionsDespite presumed equal access to healthcare and socioeconomic status within a safety-net hospital system, our results reinforce findings from previous studies showing lower colorectal cancer survival in Black patients, and also point to the importance of investigating other factors such as genetic and pathologic differences.     

Balint groups as 'shared care' in the area of mental health in primary medicine

This paper describes how Balint groups can be effective for primary care doctors and how leaders of these groups can act as role models in the interdisciplinary, experiential learning experience. The paper describes the way Balint activity helps the facilitation of a dialogue between mental health professionals and primary care physicians. While these groups have been found to improve the sensitivity of doctors in their interaction with patients, Balint groups, with the joint leadership of professionals from different disciplines, can be seen as an effective method to improve primary care and mental health cooperation. These issues are discussed and appropriate examples outlined offering an uncommon perspective on an interesting topic to promote an integrated, shared model of care.     

Moderate and Severe Obesity Have Large Differences in Health Care Costs

Objective: To analyze health care use and expenditures associated with varying degrees of obesity for a nationally representative sample of individuals 54 to 69 years old. Research Methods and Procedures: Data from the Health and Retirement Study, a nationwide biennial longitudinal survey of Americans in their 50s, were used to estimate multivariate regression models of the effect of weight class on health care use and costs. The main outcomes were total health care expenditures, the number of outpatient visits, the probability of any inpatient stay, and the number of inpatient days. Results: The results indicated that there were large differences in obesity‐related health care costs by degree of obesity. Overall, a BMI of 35 to 40 was associated with twice the increase in health care expenditures above normal weight (about a 50% increase) than a BMI of 30 to 35 (about a 25% increase); a BMI of over 40 doubled health care costs (～100% higher costs above those of normal weight). There was a difference by gender in how health care use and costs changed with obesity class. The primary effect of increasing weight class on health care use appeared to be through elevated use of outpatient health care services. Discussion: Obesity imposes an increasing burden on the health care system, and that burden grows disproportionately large for the most obese segment of the U.S. population. Because the prevalence of severe obesity is increasing much faster than that of moderate obesity, average estimates of obesity effects obscure real consequences for individuals, physician practices, hospitals, and health plans.     

Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices

The bulk of mental health services for people with depression are provided in primary care settings. Primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, and they do that with little support from specialist services. Depression is not effectively managed in the primary care setting. Collaborative care based on a team approach, a population health perspective, and measurement-based care has been proven to treat depression more effectively than care as usual in a variety of settings and for different populations, and it increases people’s access to medications and behavioral therapies. Psychiatry has the responsibility of supporting the primary care sector in delivering mental health services by disseminating collaborative care approaches under recent initiatives and opportunities made possible by the Affordable Care Act (ACA).     

How primary health care professionals and residents assess issues related to the oral health of older persons?

doi: 10.1111/j.1741‐2358.2009.00355.x
How primary health care professionals and residents assess issues related to the oral health of older persons? Background and objectives: It is known that older persons need integrated primary health care. However, oral health may not be a frequent concern of multi‐professional teams taking care of older persons. The aim of the present study was to evaluate knowledge and practices related to oral health care, as reported by professionals and residents in a primary health care service. Material and methods: One hundred and seventy‐three health professionals and residents were assessed in this cross‐sectional study by means of a structured questionnaire containing questions pertaining to oral health practices and beliefs. Participants were grouped based on their professions into “primary health care dentists” or “other primary health care professionals” and based on their working status into “permanent team” or “residents”. Results: Permanent team members (other professionals) assessed and recommended dental care more frequently than residents. Permanent team members (other professionals) also reported that they felt they were able to inform older patients in respect to oral health‐related issues more frequently than did residents (68.7% vs. 31.3%, respectively). Conclusion: Oral health‐related knowledge and beliefs were frequent among non‐dentists primary health care workers, suggesting that primary health care which integrates oral health represents an attainable goal.     

Low-intensity workers: lessons learned from supervising primary care mental health workers and dilemmas associated with such roles

The UK government's latest primary care mental health initiative, Improving Access to Psychological Therapies (IAPT), seeks to achieve its aims partly through the extensive use of low-intensity workers (LIWs). As clinical supervisors to teams of primary care mental health workers (PCMHWs) already offering brief, evidence-based interventions in primary care mental health services, we draw on the growing body of literature and our own experience to discuss dilemmas associated with the roles of such workers. These concern clinical governance, training, supervision and integration into existing services. We discuss how IAPT service characteristics may provide solutions to some of these dilemmas. We argue that it is unlikely they will be completely resolved and that IAPT services, in addressing future challenges, could benefit from lessons learned from the PCMHW role.     

Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions

Aim In the current healthcare system primary care physicians (PCPs) have, in effect, become the primary psychiatric care physicians (PPCPs) for many of their patients. Being the PPCP in an already busy and stressful medical industry presents additional time management and treatment challenges to successfully manage patients' medical and psychiatric needs. The aim of the study was to ascertain PCPs' psychiatric assessment and treatment practices and to determine the extent to which PCPs have a need for using a structured psychiatric assessment tool.Method We sent 300 PCPs a survey to examine their psychiatric assessment and treatment practices. A one-page questionnaire was used to inquire about PCPs' psychiatric care practice habits including types of conditions treated, psychiatric medications prescribed, assessment methods used, interest in using a structured assessment tool and referral sources used. Sixty-eight usable surveys (23%) were returned.Results PCPs identify approximately one-third of their patients as mental health patients. They are treating a wide range of psychiatric conditions and prescribing a variety of psychiatric medications. The vast majority are using traditional clinical interviewing as their primary method of psychiatric assessment. However, the majority were willing to use a structured psychiatric assessment tool.Conclusion PCPs are serving a useful role in providing psychiatric treatment to many of their patients. Using a more structured psychiatric assessment method in practice could ultimately strengthen the assessment and treatment of psychiatric conditions in primary care settings.     

Community-based mental health care in Africa: mental health workers’ views

The World Health Organization (WHO) has for long proposed the development of community-based mental health services worldwide. However, the progress toward community mental health care in most African countries is still hampered by a lack of resources, with specialist psychiatric care essentially based in large, centrally located mental hospitals. It is again time to reconsider the direction of mental health care in Africa. Based on a small inquiry to a number of experienced mental health professionals in sub-Saharan Africa, we discuss what a community concept of mental health care might mean in Africa. There is a general agreement that mental health services should be integrated in primary health care. A critical issue for success of this model is perceived to be provision of appropriate supervision and continuing education for primary care workers. The importance of collaboration between modern medicine and traditional healers is stressed and the paper ends in a plea for WHO to take the initiative and develop mental health services according to the special needs and the socio-cultural conditions prevailing in sub-Saharan Africa.     

Global Health Care Justice,Delivery Doctors and Assisted Reproduction: Taking a Note From Catholic Social Teachings

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution.     

Obesity and the Use of Health Care Services

Objective: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. Research Methods and Procedures: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self‐reported health status using the Medical Outcomes Study Short Form‐36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. Results: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. Discussion: Obesity is a chronic condition requiring long‐term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity‐related diseases will continue to grow, resulting in escalating use of health care services.