Managed public mental healthcare: issues, trends, and prospects.
OBJECTIVE: To describe the structure and status of public mental healthcare and the impact of managed behavioral healthcare on this system. STUDY DESIGN AND METHODS: The structure and financing of public mental health systems were reviewed. Because there are no controlled multisite studies of managed public sector behavioral healthcare, case examples were used to illustrate trends and issues. DISCUSSION: The methods, results, and impact of public managed behavioral healthcare are incomplete and uncertain. The complexity of the public sector system, the patients served in it, and the services provided are daunting. The variability of patient needs, the role of Medicaid versus state funding, and the variable governance structures of local systems in different states make managed care methods more complex than in private markets. CONCLUSIONS: The organization, structure, and financing of public mental health systems have developed rapidly in the past generation as care has been moved from hospital to community. Early efforts to apply managed behavioral healthcare methods used in the private, commercially paid sector have not been very successful, and most public sector managed care efforts have been limited to Medicaid-paid care. The trend in public mental health systems is to "unpack" managed care and use its tools selectively.