This article describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.

Using national data and the most recent OECD figures, we provide an updated assessment of the Spanish health care system and its reforms. We compare figures from Spain with other major industrialized nations and find that the Spanish system appears macro-economically efficient and equitable. However, like many other countries in Europe and elsewhere, the Spanish health care system confronts continued pressures to provide high-quality universal care in the face of ever increasing costs and competing uses for financial resources. These pressures have prompted the enactment of several reforms, which are reviewed. We draw from the American experience with managed care and managed competition to illustrate possible paths for further reform.