A continuum of managed care options has evolved reflecting differing health care market characteristics. Alternative health plans are increasing, outdistancing the “gold standard” staff model HMOs. A dizzying array of options, however, has led to considerable confusion. Direct contracting has evolved as a way for employers to understand what they are paying for and to managed costs. Increases in managed care, and a degree of financial distress, will encourage the development of integrated networks. National reform is unlikely to convert today's loosely structured system to a fully integrated system overnight, but will stimulate managed care in markets sooner than otherwise expected.