When does big become too big for optimal patient care?

Current efforts at health care reform seem focused on two interrelated areas--an emphasis on cost containment through the shift to managed care and the expansion of managed care organizations through mergers and acquisitions. At some point, one could question whether interorganizational competition, or organizational size and the resulting complexity and fragmentation of the work force, might not lead to difficulties in providing high-quality care, as well as the avoidance of certain clients and patient populations deemed too small to provide the scales of economy required to maintain these large organizations. The following articles examine some of these questions.