The high cost of medical care has created a crisis in access and quality of services for many in the United States and has led to rapid changes in the structure and financing of health services. Managed care and managed competition are terms and techniques that have been invented in an effort to get a handle on the escalating cost of care. As a percentage of the gross national product and in actual dollars, health care expenditures have risen significantly. In 1980, the national health expenditure represented 9.1% of the gross national product. By 1985, this had risen to 10.5% and by 1992, to 12.1%, or just over $800 billion.

The rising costs of health care and other benefits have left little room for real growth in wages and salaries. According to data in a 1990 report, the average total compensation for full-time workers including wages, health care, pension benefits, and other contributions rose to $29,712 in 1989 from an inflation adjusted $28,117 in 1973. Only $273 of the $1595 gain went to wages and salaries, whereas $878 of the increase went to health insurance and $440 went to other forms of benefits. In 1973, group health benefits accounted for 2.3% of workers' total compensation; by 1989, that had risen to 5.1% of total compensation.<sup>31 US Department of Commerce Health and medical services US Industrial Outlook 1990 ;  49 : 1-6

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These pressures on corporation and household budgets of health bills have forced many of the changes that we are experiencing in the new market for health and mental health care. A broad consensus now exists among all payors, including the government and the private sector, that health care costs must be constrained and reined in.