View from the bridge: reflections of a recovering staff model HMO psychiatrist.

The phenomenon of managed care is misperceived by its critics as a movement. Atheoretical in nature, and driven by spiralling health care costs, it represents the introduction of an executive function into the free-for-all (a supremely ironic term) of American medicine. Part one of this article traces the origin and development of the mental health carve-out, relating it to its antecedents, and describing its 3 overlapping phases: utilization review, discounted fees, and network development and management. Part two describes the key concept of the continuum of care and the role of the case manager in monitoring a care episode. The article concludes by anticipating seven future trends and calling for mental health leadership to recognize and ally with the need to manage resources in a more rational and efficient manner.