Managed care refers to processes or techniques used by, or on behalf of, purchasers of health care that seek to control or influence the quality, accessibility, utilization, and costs of health care. Managed care emerged in the United States in the 1960s as a response to rising health care costs, and consists of different types of organizational practices to make health care more efficient and effective. Most other industrial countries have also responded to rising health care costs by managing care. Managed care emphasizes cost containment, performance assessment, and measurable outcomes and subjects the treatment actions of health care providers to external review. Treatment decisions are evaluated in light of measurable client-level outcomes; consequently, managed care has resulted in a greater emphasis on accountability. The issue is whether accountability is accessed in terms of cost savings (efficiency) or enhanced care (effectiveness). In the United States, managed care often involves a greater concern with cost savings than with enhanced quality or access.