The prospects for prepaid long-term care: the Arizona Medicaid experiment

Arizona is adding long-term care to its prepaid, capitated alternative to Medicaid. This article discusses the potential for this major cost-control experiment. Experience suggests that those able to quality for long-term care will fare better than the poor did in the previous system. However, limiting eligibility will be the primary means of controlling costs; significant price competition is not likely to develop. The bidding process will serve more to transfer risk to contract providers than to improve program efficiency. Potential cost savings will be more than offset by an increased identification of need.     

Regulatory policy and information deficiencies in the market for mental health services

This paper addresses issues related to the regulation of the delivery of mental health services. The focus is primarily on regulations that are aimed at dealing with the consequences of imperfect information in the marketplace. The paper reviews and assesses what is known about the impact of regulations on efficiency and equity. One conclusion is that we know a fair amount about impacts of regulation on prices for mental health service and very little about effects on quality of care. A research agenda is proposed based on the knowledge available in 1988.     

COMPETITIVE TENDERING IN THE NHS: AN ECONOMIC ANALYSIS' OF THE EARLY IMPLEMENTATION OF HC(83)18

Economic theory identifies circumstances where in-house production can be expected to be more efficient, in terms of the cost of production, than purchase from outside contractors. However, this efficiency advantage can also expect to be dissipated when in-house producers face no competition. The introduction of competitive tendering does not invalidate the case for in-house production; but significant cost savings can still be expected.
An in-depth analysis is made of six contracts put out to tender in the three hotel-type services. Markets for contracts were created, and open competition commonly brought about savings of one-third to two-thirds. Part of the cost saving was often achieved through a rationalization of services. Economic theory does not predict this result; but NHS management used the opportunities to introduce changes. Wage rates were usually cut and earnings fell by still more. Staff resignations and redundancies were common.     

Drug use and pretrial misconduct in New York city

Is recent drug use significantly associated with pretrial misconduct? Does consideration of recent drug use enhance risk classification among a sample of persons who have time free pending the disposition of their cases? Using data on arrestees in Manhattan, this paper examines these issues and some related questions. To measure recent drug use, urine samples were collected from persons shortly after their arrest and tested for four drugs: heroin, cocaine, PCP, and methadone. Two measures of pretrial misconduct are considered: whether a defendant fails to appear for a scheduled court date (FTA) and whether a defendant is rearrested prior to case disposition. Censored probit models are used to estimate the statistical association between drug test results and pretrial misconduct. Results show that drug test results are significantly associated with pretrial misconduct over and above the information typically available to judges at the time release decisions are made. Some implications of these findings for pretrial decision making are discussed.     

Ultrastructural pathology of mechanical skeletal muscle damage

In continuation of previous light microscope investigations the question has been raised whether the criteria determined for vital muscle damage using light microscopy, could be verified and perhaps extended for the ultrastructural region. In addition to existing human pathological material taken early post mortem, muscle tissue obtained from animal experiments was also examined. The evaluation concentrated on the muscle cells, the cell organelles and the contractile apparatus. An evaluation of semi-thin-sections was carried out in parallel. The following reaction patterns could be defined as vital reactions: hypercontraction bands, zones of rupture in narrow topological relationship to organelle changes, microstructure changes with disintegration of the fibre structure, subsarcolemmic and interfibrillary oedema, decomposition of the sarcolemma. The earliest vital reactions were detectable after only a few minutes survival time. The comparison between the results of animal experiments and human pathology and the application of the results to forensic pathology will be discussed.     

Postmortem redistribution of digoxin in rats

Adult male Wistar rats were treated with either 0.1 or 3 mg/kg body weight X day of digoxin for five days, then killed and stored at 4 degrees C for 12 h in an attempt to mimic the normal preautopsy procedures in our hospital. In rats treated with 0.1 mg/kg body weight X day, the antemortem serum digoxin concentrations (SDC) were 1.1 +/- 0.4 ng/mL while the 12-h postmortem concentration was markedly increased (16.3 +/- 5.9 ng/mL) (P less than 0.01). In rats treated with 3 mg/kg body weight X day, SDC was not changed significantly (11.2 +/- 4.8 ng/mL antemortem and 13.3 +/- 6 ng/mL postmortem). Postmortem redistribution of digoxin was assessed by injection of 125I-labelled digoxin with or without pretreatment with the unlabelled drug. The results indicate that after death passive redistribution of digoxin may take place. When the SDC are within the therapeutic or low toxic range, digoxin may reenter the blood. High antemortem serum concentrations of digoxin may prevent such passive redistribution. Therefore, antemortem digoxin intoxication cannot be reliably inferred on the basis of high postmortem levels of the drug. Digoxin intoxication can be ruled out when postmortem SDC remain within the therapeutic range. The above changes cast doubt on some of the forensic and cardiologic literature, which has in the past been based on incorrect assumptions concerning postmortem behavior of digoxin.