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Sharfstein, 1990, pp. 965-966). The concept of managed care derived from the cost containment crisis in the delivery of health care services in the United States (Relman, 1993, pp. 133-135).

Dynamic change characterizes the American health care environment in the 1990s (Hammonds, 1994, pp. 48-57). Within such an environment, care providers and support organizations must develop and implement new and effective strategies if they are to remain viable entities. The changes in the health care environment result from a combination of factors--increasing costs of health care

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