Sharfstein S S, Stoline A M, Goldman H H
Sheppard and Enoch Pratt Hospital, Baltimore, MD 21285-6815.
Am J Psychiatry. 1993 Jan;150(1):7-18. doi: 10.1176/ajp.150.1.7.
Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.
对美国医疗保健的成本、可及性和质量的担忧引发了一系列立法提案，这些提案旨在改革我们的医疗保健系统及其融资方式。包括药物滥用在内的精神疾病的医疗保险福利与医疗/手术福利有所不同，门诊就诊次数和住院天数受到更严格的限制。与一般医疗疾病相比，医疗保险、医疗补助以及大多数私人医疗保险计划在精神疾病的覆盖范围上存在这种历史性差异。精神科服务也因其在精神疾病治疗和支持方面有大量公共部门报销而有所不同。更公平设计精神健康福利的原则包括非歧视性方法；基于服务而非诊断进行支付；在与一般医疗疾病护理相同的基础上对精神疾病护理实施成本控制；保留公共部门作为高成本、长期护理的后备系统；通过发展连续护理鼓励采用成本较低的替代住院治疗的方法；以及认识到心理治疗和医疗管理之间的区别。目前所有的全民医疗保健方法都未能达到这些原则。现在比以往任何时候都更需要一个研究议程，以便阐明全面覆盖精神疾病和药物滥用的理由。
