Markets and Medical Care: Supplementary Analysis
Markets and Medical Care:
Supplementary Analysis
Joseph White, Ph.D.
Luxenberg Family Professor of Public Policy
Director, Center for Policy Studies
Department of Political Science
Case Western Reserve University
May, 2007
Mather House 111
11201 Euclid Ave
Cleveland, OH 44106-7109
(216) 368-2426
(216) 368-4681 fax
joseph.white@case.edu
This document is a supplement to “Markets and Medical Care: The United States, 1993-2005,” which is scheduled for publication in The Milbank Quarterly,
Fall 2007.
It has not been edited.
Abstract
An extensive literature argues for or against markets in principle as a way of financing medical care. In “Markets and Medical Care: The United States, 1993-2005,” I argue that a health care finance system characterized by suppliers’ individual pursuit of profit, suppliers having extensive access to capital, and extensive shopping (by employers) for care, seemed for a few years to improve cost control. In fact that was a temporary phenomenon, driven by discounting in response to dominant stories about the future. Cost experience was driven far more by market power over prices than by management of utilization. When both supply conditions and market psychology changed, cost increases returned with a vengeance. System transformations were driven by access to capital and the ephemeral beliefs of system decision-makers rather than by logics of either efficiency or equity. Within the overall labor and capital market arrangements of the United States, market competition had shown little ability to rationalize health care systems, because the goals of market competition are not those of the kind of health care system most people would desire. In this paper I address concerns raised by one reviewer of the original paper, who suggested I discuss more recent developments such as “Pay for Performance” and “Consumer-Directed Health Care.” I find that the facts about these two phenomena through 2006, as well as developments with the role of private plans within Medicare, fit the argument in the original paper.
With the failure of managed care, believers in markets as the solution to health care problems have moved on to other ideas. A reviewer of the first version of “Markets and Medicare” commented that, “the author doesn’t address two ‘hot’ developments in the market at present: ‘pay for performance’ and ‘consumer-directed healthcare.’ I do not mean to imply that I think these are wonderful, and certainly a great deal of herd psychology is at work, but they are important and they might illustrate how the market evolves.” There is little evidence that these ideas are being implemented in ways that have important substantive effects. Yet they do provide good illustrations of how a desperate search for alternatives and attraction to stories with nice images can influence policy discourse, while the realities of implementation and self-interest are ignored amid the hype.
“Consumer-directed” health care is the more significant of these ideas, because it has justified restructuring of insurance for a small subset of enrollees. The theory calls for encouraging enrollees to have insurance with high deductibles, so that they would have to think more about initial purchases of health care. The potentially negative effects of the deductibles, then, would be mitigated by allowing (and to some extent having employers fund) Health Savings Accounts. Individuals would have incentives not to consume because the accounts could eventually be used for other purposes, but would be able to use those funds for care that seemed especially necessary.
This is not the place for an extensive review of the HSA concept. Yet it seems worthwhile to note that “consumer direction” is, first of all, rhetoric. It could as accurately be labeled “consumer constraining” health care, since the theoretical point of high deductibles is precisely to create price constraints to inhibit consumption. Beyond the rhetoric, the idea faces a series of practical difficulties.
First, if consumers were to “take charge” of their health care they would need a great deal of information, and the ability to process that information. The latter may never exist; the former is not exactly in high supply. GAO, for example, found that plans offered to federal employees provided standard information about healthy behavior, but little about quality and cost of alternative providers (GAO 2006a: 17-18). Rosenthal and colleagues (2005: 1592) observed that most
“first generation consumer-directed health plans… do not make available
alternative measures of quality and longitudinal cost-efficiency in enough
detail to help consumers discern high-value health care options; financial
incentives for consumers are weak and insensitive to differences in value
among the selections that consumers make; and none of the plans made cost-
sharing adjustments to preserve freedom of choice for low-income consumers.”
In other words, so far “consumer-directed” health plans are no more “consumer-directed” than most “managed care” plans actually manage care. “CDHP” is mainly a relabeling of high-deductible insurance, so a very old-fashioned cost control idea.
Yet even the level of cost-sharing in many plans is not evidently greater than for common private insurance. Remler and Glied (2005: 1070) point out that with funds in an HSA available to pay for part of the deductible, and with the deductible replacing cost-sharing above its maximum amount (e.g. copays for prescriptions), “many HSA/high-deductible arrangements would actually reduce cost-sharing for many groups. In particular, the group responsible for half of all medical spending would see no change or a decline in cost-sharing at the margin and on average.” Hence these plans are not necessarily even more consumer-constraining than the alternatives! Just as the hype about HMOs enabled both supporters and critics to ignore differences between actual plans and the ideal of a tightly-managed group/staff system, the sound and fury about high-deductible approaches conceals the variation among plans.
High-deductible plans also remain a very small part of American health insurance. Table 1 does show that enrollment in high-deductible plans has reached a level where it can be observed and measured. All figures of course are from surveys, and there is some disagreement among sources. Yet by any figures they still “have barely gained a toehold among Americans with employer-sponsored insurance” (Gabel et al. 2006: 1), with about 3 million enrollees in 2006. In Gabel et al’s data, estimated enrollment only grew by 300,000, to 2.7 million workers in employer-sponsored high-deductible plans, between 2005 and 2006. Of these, over a million — 39 percent – “had no choice of another type of plan” (Gabel et al 2006: 1). Although there appear to have been some savings for some employers, effects are difficult to estimate because of favorable selection (Buntin et al. 2006: w521-w523). If employers contribute to the accompanying savings accounts, their net savings are at best small (statistically insignificant in the Kaiser Foundation survey; Gabel et al 2006: 2). Given a choice, only about a fifth (19%) of employees have chosen high-deductible plans. One reason may be that employers have not in general made large contributions to the accompanying savings instruments, in part to guard against selection bias. Hence a “key concern” for employers is that, “by providing a spending account to all employees, employer payments might increase for their healthy workers” (Trude and Conwell 2004: 2). The evidence overall does support concerns about healthier individuals selecting high-deductible plans (Buntin et al 2006).
The pattern to date of promotion and adoption of “consumer-directed” insurance therefore fits well with my essay’s emphasis on the roles of hype and stories within markets, and offers little evidence that “market forces” will fix American health care problems. Yet if the approach has yet to become as significant as the number of pages devoted to it in Health Affairs might lead one to expect, that may tell us more about the health policy community than about markets. We need to be cautious about interpreting policy discussion as reflecting what people are actually doing.
The case of “Pay for Performance” is a more extreme case of confusion between policy talk and market developments. It is widely agreed that payers, including Medicare, have little information as to the quality of the care they are buying. As a result, there is a great desire among policy elites, such as the MedPAC commissioners, for measures that would “build financial incentives for quality” into payment systems (Milgate and Cheng 2006). Although both many private payers and Medicare have created “pay for performance” demonstration projects, implementation of measures that pay providers according to measures of performance remains a miniscule part of health care payment. Careful analysis of results is rare, in part because of the difficulty of direct measurement and in part because it is especially difficult to identify unintended consequences, such as how extra payment for particular services may divert attention from equally important, but now less remunerative, services.
As of 2003 there were a grand total of seven “published, peer-reviewed, empirical studies of the effects” of trying to pay for quality in health care (Rosenthal and Frank 2006: 141), and one had no control group. Of the six others, all involved paying fees to physicians to provide extra services such as screening and vaccinations, and even so three showed no significant effects. The Center for Studying Health System Change found “lots of buzz, little action” on P4P for physician services in its study markets (Bodenheimer et al 2005: 1). Of 36 hospital programs identified in 2005, only a minority included actual outcome measures (Nichols and O’Malley 2006).
The strongest evidence against taking Pay for Performance seriously, however, comes from its most prestigious endorsement: a National Academy of Medicine study panel report that recommends “P4P” for Medicare (Committee on Redesigning Health Insurance 2006). The study reported there were over 100 reward and incentive programs in the private sector, but “most of these efforts have not yet been fully evaluated.” The committee added that Medicare administrators had also implemented some demonstration projects, and “some of these programs have begun to show that providers respond positively to payment incentives… but it remains unknown whether the improvements seen will be significant and sustained. The literature evaluating the effectiveness of pay-for-performance consists of fewer than 20 studies, yielding mixed conclusions on overall impact” (Committee on Redesigning Health Insurance 2006: 3). The study committee reported that it would be nice to pay for higher quality with savings generated by the same measures, but, “these efficiencies have not yet been adequately demonstrated in pay-for-performance efforts” (Committee on Redesigning Health Insurance 2006: 7).
So in essence they were recommending that Medicare pay providers extra fees for certain services, mostly procedures that by some theory are connected to quality. This isn’t pay for performance, it’s fee-for-service. We can reasonably assume that paying extra fees will generate extra services, and in fact we have one very convincing piece of evidence to that effect. When the British National Health Service adopted its much more extensive initiative, in the first year it cost $700 million more than projected because, offered new fees, British General Practitioners greatly increased either their level of services or their documentation of services (Galvin 2006). But that example also shows that there is no logical relationship between seeking to pay for performance and organizing medical care as a market.
A third development which may be used to make positive claims about markets is the implementation of the 2003 Medicare prescription drug legislation. Contrary to many projections, private insurers and other firms have participated eagerly in the new prescription drug insurance, offering a large number of plans in every market (Gold 2006a). Many plans offered lower premiums than projected. With a few exceptions (Krasner 2007), the stand-alone prescription drug plans (PDPs) did not raise premiums or alter formularies substantially between 2006 and 2007 (Hoadley et al. 2006). Although seniors’ impressions of the drug benefit plan were more negative than positive through most of 2006, by November they were moderately favorable. Medicare beneficiaries who chose to get their Parts A and B Medicare benefits along with their Part D drug benefit from private “Medicare Advantage” plans were offered significantly lower premiums or enhanced benefits for drug coverage; many of these plans charged no premium for drug coverage (Gold 2006b, Cubanski and Neumann 2006). Enrollment in private insurance plans within Medicare grew sharply, from 12.8% of beneficiaries in December of 2004, to 17.2% in December of 2006 (Kaiser Family Foundation 2005, 2006, 2007).
The growing enrollment in Medicare Advantage plans, however, provided no evidence of the plans’ efficiency. Both the MMA of 2003 and administrative decisions made by the Centers for Medicare and Medicaid Services tilted the playing field dramatically in favor of enrolling in private plans. The payment rules and adjustments caused Medicare Advantage plans to be paid 12.4 percent more than the costs for the same patients in traditional Medicare in 2005 (Biles et al. 2006), and 11 percent of what it would have cost to provide the same services in the traditional fee-for-service program in 2006 (MedPAC 2006a: 2). The average excess payment to Medicare Advantage plans was more than twice the average beneficiary premium for stand-alone PDP coverage! It should be no surprise that the Medicare Advantage plans could offer better benefits at a lower price.
At approximately a thousand dollars per beneficiary in extra payments from the federal treasury, Medicare Advantage plans were not a solution to the challenge of controlling health care costs, but part of the problem. The law favored them in other, more subtle ways, such as that the marketing costs for a Medicare Advantage plan would be spread over a much larger premium base than the marketing for a stand-alone PDP. In addition, two kinds of private plans, Regional PPOs and Private fee-for-service, were allowed to use the Medicare fee-for-service rate schedules to pay providers (MedPAC 2006b). In short, private insurers were allowed to piggy-back on traditional Medicare’s bargaining power!
Even with this extra help, regional PPOs received very little enrollment, validating the doubts raised by Hurley et al (2004) and in this paper. But Private Fee-for-Service, unlike PPOs, did not require restricted networks. PFFS plans could offer customers the full traditional Medicare set of providers; pay the providers the same amount regular Medicare paid them; and use the roughly thousand dollars in excess revenue partly to provide extra drug benefits and partly for profits. As a result, 45% of the growth in Medicare Advantage enrollment between 2005 and 2006 consisted of a quadrupling of enrollment in the PFFS plans. At the 2006 Wall Street to Washington gathering, Paul Ginsburg commented that the insurers, “have found a golden goose here.” This was not the private sector doing a better job than the government, but the government subsidizing private profits.
The somewhat lower than expected premiums and extent of choices for coverage through private PDPs and Medicare Advantage plans were, as noted, better than some expectations, and better than some alternatives. The premiums in part reflected a general slowdown in the increase in costs for pharmaceuticals. This appeared to be partly a result of useful application of price constraints through tiered cost-sharing that provided incentives to consume less expensive drugs; partly a result of a slowdown in development of blockbuster drugs, partly from some major preparations going off-patent, and partly from a few being withdrawn from the market (Ginsburg et al. 2006).
Both participation and decisions about premiums to charge, however, reflected business calculations that had little to do with health care logic. Discussions of the Medicare PDP business look a lot like analyses of the rest of the health care business. Marsha Gold explained that firms entered the market with different strategies based in part on the market segments (such as pharmaceutical benefits management, or medigap insurance) that they might try to protect. Both the count of plans and enrollment was dominated by the set of large insurers that also dominated employer-based health insurance, with a few smaller insurers seeking small segments. Within this context Pacificare and Humana, for example, sought opportunities in Medicare Advantage fee-for-service; United Healthcare sought to build on its pre-existing partnership with AARP for Medigap coverage. Large Medigap insurers (United American) offered PDPs and considered moving into Medicare Advantage if it did not require too much work (e.g. through Private Fee-for-Service plans). Plans that already offered Medicare HMOs could fear loss of enrollment, “particularly from less price sensitive beneficiaries who may have been attracted to them mainly because they were the only available source of prescription drug coverage,” so more comprehensive plans diversified into the stand-alone PDP market (Gold 2006: 22). In short, “offering a broader product spectrum” allowed many firms to “hedge their bets” (Gold 2006: 23).
While the stand-alone PDPs were not subsidized in the same way as the Medicare Advantage plans, the payment system also made it very unlikely that they could lose money, so further encouraged market entry. Much of the risk of higher expenses than projected was covered by the federal government through “risk corridors.” As a result, if plan managers expected to spend 85% of revenues on drug costs (“medical loss,”) 10 percent on other costs and have a 5 percent margin, one Wall Street analyst explained, medical costs would have had to be 19 percent higher than anticipated to turn that 5 percent profit into breaking even (Health System Change 2006: 6). These subsidies – risks borne by the federal government — made the risks of staying out of the Medicare prescription drug business, in terms of lost business in other lines (e.g. pre-existing Medicare + Choice, or pre-existing Medigap), seem greater than the risks of getting into the Medicare prescription drug business.
Market analysts also explained that firm managers tend to feel impelled to tell Wall Street a story about continued growth. Since the big insurers were not competing to manage care differently (so grow by offering greater value), that left two approaches. One was to have mergers (as would happen with United Healthcare and Pacificare in 2006). Another would be to enter new product lines (Health System Change 2005: 7). In this context, firms that didn’t enter the Medicare PDP and Medicare Advantage markets would have taken a risk by refusing to enter a market that other firms entered. Other firms would have grown, relatively, making the managers of the reluctant firms look bad in the financial marketplace. Hence managers who stayed out of the PDP and MA markets did so at their own (personal) risk.
Market analysts, including from both Goldman Sachs and Citigroup, also recommended that insurers promote stand-alone Part D plans as “loss leaders…to lure beneficiaries into more lucrative MA plans” (Oberlander 2007). The managers of Humana chose to follow this strategy. They saw Medicare Advantage as the place to make big money, but seniors as resistant to those plans. So they followed an “enroll and migrate” strategy. As Business Week reported, the strategy was to offer “dirt cheap” PDP plans “to grab millions of seniors.” One analyst described the approach as, “let’s get them into a [drug plan] at a modest margin or even no margin in Year One, then try to convert them to” a Medicare Advantage product. Many of the lowest-priced plans across the country therefore were Humana plans, with premiums trending $20 per month below the average (Gleckman 2006). As a result, Humana became second to United Health Care/Pacificare (which had the AARP linkage) in stand-alone PDP enrollment with over 3.4 million enrollees, 20 percent of the total (Cubanski and Neuman 2006).
By the end of 2006 Humana’s approach appeared especially daring, as the short-term consequences were not looking good at all. In the 3rd quarter of 2006 Humana spent 93% of premiums on medical expenses (a 93% MER, or Medical Expense Ratio) for its stand-alone PDPs. That was due mainly to a 133 % MER for its most generous, “Medicare Complete” plan (Humana Inc. 2006). Humana responded by substantially reducing its Medicare Complete benefit; the optimistic interpretation would be that it expected those enrollees to quickly “migrate.” United Healthcare’s financial reports also were somewhat muted, noting an “operating profit” on Part D business during the third quarter, when profits had been expected as beneficiaries moved into the no-payments donut hole, but providing no details (UnitedHealth Group 2006).
Overall, hopeful conclusions about markets from free-standing PDPs would not be as misleading as positive conclusions from the Medicare Advantage patterns. Medicare Advantage has basically been a giveaway, raising Medicare costs. One may reasonably conclude that private insurers at least have been able to get a bit of cost control from tiered formularies for Medicare PDPs, just as they have for employment-based insurance. Differential cost-sharing, however, is a cost-control method that can be used by public as well as private actors. Whether cost controls had been successful enough to justify the premiums was by no means established as of the beginning of 2007, as the financial reports began to trickle in. Meanwhile, dynamics such as needing to show growth to the financial markets, and an absence of competition based on efficiency, looked very much like the story from the account of 1993-2005.
TABLE 1
Estimated Health Plan Enrollment By Type of Plan
Selected Years, 1988-2006
Conven- High
YEAR tional HMO PPO POS Deductible
1988 73% 16% 11% * *
1993 46% 21% 26% 7% *
1996 27% 31% 28% 14% *
1999 10% 28% 39% 24% *
2002 4% 27% 52% 18% *
2005 3% 21% 61% 15% *
2006 3% 20% 60% 13% 4%
________________________________________________________________________
Source: Claxton et al. 2006, Exhibit 6, page W482.
Note that these results are estimates based on surveys; there is no actual record of enrollment by plan type, or any other enrollment record, in the United States.
Note also that the surveys involved did not ask about high-deductible health plans – currently frequently mislabeled “consumer-directed” plans – until 2006.
Sources
Bertko, John. 2004. “Commentary – Looking at the Effects of Consumer-Centric Health Plans on Expenditures and Utilization.” Health Services Research 39, no. 4, Part II, pp. 1211-1218.
Biles, Brian, Lauren Hersch Nicholas, Barbara S. Cooper, Emily Adrion, and Stuart Guterman. 2006. The Cost of Privatization: Extra Payments to Medicare Advantage Plans – Updated and Revised. The Commonwealth Fund, New York (November).
Bodenheimer, Thomas, Jessica H. May, Robert A. Berenson, and Jennifer Coughlan. 2005. “Can Money Buy Quality? Physician Response to Pay for Performance.” Center for Studying Health System Change Issue Brief 102 (December).
Buntin, Melinda Beeuwkes, Cheryl Damberg, Amilia Haviland, Kanika Kapur, Nicole Lurie, Roland McDevitt, and M. Susan Marquis. 2006. “Consumer-Directed Health Care: Early Evidence About Cost and Quality.” Health Affairs Web Supplement, 24 October, pp. W516-W530.
Committee on Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Programs, Board on Health Care Services. 2006. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: National Academies Press.
Cubanski, Juliette and Patricia Neuman. 2006. “Status Report on Medicare Part D Enrollment In 2006: Analysis Of Plan-Specific Market Share and Coverage.” Health Affairs Web Exclusive (November 21), pp. W1 – W12.
Davis, Karen. 2004. “Consumer-Directed Health Care: Will It Improve Health System Performance?” Health Services Research 39, no. 4, Part II, pp. 1219-1233.
Gabel, Jon, Jeremy Pickreign and Heidi Whitmore. 2006. “Behind the Slow Enrollment Growth of Employer-Based Consumer-Directed Health Plans.” Center for Studying Health System Change Issue Brief 107 (December).
Galvin, Robert. 2006. “Pay-for-Performance: Too Much of a Good Thing? A Conversation With Martin Roland.” Health Affairs Web Supplement, pp. W412-W419.
Gauthier, Anne K. and Carolyn Clancy. 2004. “Consumer-Driven Health Care: Beyond Rhetoric with Research and Experience.” Health Services Research 39, no. 4, Part II, pp. 1049-1054.
Ginsburg, Paul B., Bradley C. Strunk, Michelle I. Banker, and John P. Cookson. 2006. “Tracking Health Care Costs: Continued Stability But At High Rates In 2005.” Health Affairs Web Supplement (3 October), pp. W486-W495.
Gleckman, Howard. 2006. “Plan A: Hook Them With Part D.” Business Week, January 30.
Gold, Marsha. 2006a. “The Landscape of Private Firms Offering Medicare Prescription Drug Coverage in 2006.” Henry J. Kaiser Family Foundation, March.
——-. 2006b. “Premiums and Cost-Sharing Features in Medicare’s New Prescription Drug Program, 2006.” Henry J. Kaiser Family Foundation, May.
Hoadley, Jack, Elizabeth Hargrave, Juliette Cubanski and Tricia Neuman. 2006. “An In-Depth Examination of Formularies and Other Features of Medicare Drug Plans.” Henry J. Kaiser Family Foundation, April.
Hoadley, Jack, Elizabeth Hargrave, Katie Merrill, Juliette Cubanski, and Tricia Neuman. 2006. “Benefit Design and Formularies of Medicare Drug Plans: A Comparison of 2006 and 2007 Offerings – A First Look.” Henry J. Kaiser Family Foundation, November.
HSChange (Center for Studying Health System Change). 2005. “10th Annual Wall Street Comes to Washington Conference.” Transcript, July 13. at http://hschange.org/CONTENT/765/?words=Wall+Street+to+Washington
——-. 2006. “11th Annual Wall Street Comes to Washington Conference.” Transcript, June 21. at http://hschange.org/CONTENT/854/?PRINT+1
Humana Inc. 2006. “Humana Inc. Reports Third Quarter 2006 Financial Results including Earnings per Share of $0.95.” News Release, October 30.
Hurley, Robert E., B.C. Strunk and J.S. White. 2004. “The Puzzling Popularity Of the PPO.” Health Affairs 23, no. 2, pp. 56-68.
Kaiser Family Foundation. 2005. “Medicare Advantage and Medicare Beneficiares.” Monthly Tracking Report for December 2004. Downloaded from http://www.kff.org/medicare/upload/Medicare-Advantage-and-Medicare-Beneficiaries-Monthly-Tracking-Report-for-December-2004.pdf.
——-. 2006. “Tracking Medicare Health and Prescription Drug Plans” Monthly Report for December 2005. Downloaded from http://www.kff.org/medicare/upload/medicaretracking1205.pdf
——-. 2007. “Tracking Medicare Health and Prescription Drug Plans.” Monthly Report for December 2006. Downloaded from http://www.kff.org/medicare/upload/medicaretracking1206.pdf
Kaiser Family Foundation/Harvard School of Public Health. 2006. “Seniors and the Medicare Prescription Drug Benefit.” Chartpack, downloaded January 14, 2007 from http://www.kff.org/kaiserpolls/upload/7604.pdf
Krasner, Jeffrey. 2007. “Menino Calls for Humana Inquiry.” Boston Globe, January 3.
Lo Sasso, Anthony T., Thomas Rice, Jon R. Gabel, and Heidi Whitmore. 2004. “Tales from the New Frontier: Pioneers’ Experiences with Consumer-Driven Health Care.” Health Services Research 39, no. 4, Part II, pp. 1071 – 1089.
Medicare Payment Advisory Commission (MedPAC). 2006a. “Medicare Advantage Benchmarks and Payments Compared With Average Medicare Fee-for-service Spending.” Medicarebriefs (June 9),
http://www.medpac.gov/publications/other_reports/MedPAC_briefs_MA_relative_payment.pdf
——-. 2006b. Report to the Congress: Increasing the Value of Medicare. Washington, DC: MedPAC.
Milgate, Karen, and Sharon Bee Cheng. 2006. “Pay for Performance: The MedPAC Perspective.” Health Affairs 25, No. 2, pp. 413-419.
Nichols, Len M. and Ann S. O’Malley. 2006. “Hospital Payment Systems: Will Payers Like the Future Better Than the Past?” Health Affairs 25, No. 1, pp. 81-93.
Oberlander, Jonathan. 2007. Through the Looking Glass: The Politics of the Medicare Prescription Drug, Improvement, and Modernization Act. Journal of Health Politics, Policy and Law 32(2): 187-220.
Perry, Michael, Adrianne Dulio and Juliette Cubanski. 2006. “Voices of Beneficiaries: Medicare Part D Insights and Observations One Year Later.” Henry J. Kaiser Family Foundation, December.
Remler, Dahlia K, and Sherry A. Glied. 2005. “How Much More Cost Sharing Will Health Savings Accounts Bring?” Health Affairs 25, No. 4, pp. 1070-1078.
Rosenthal, Meredith, and Richard G. Frank. 2006. “What is the Empirical Basis for Paying for Quality in Health Care?” Medical Care Research and Review 63, No. 2, pp. 135-157.
Schoen, Cathy, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Jordon Peugh, and Kinga Zapert. 2006. “On the Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences, And Views In Seven Countries.” Health Affairs Web Supplement, November 2, pp. W555-W571.
Trude, Sally and Leslie Conwell. 2004. “Rhetoric vs. Reality: Employer Views on Consumer-Driven Health Care.” Center for Studying Health System Change Issue Brief 86 (July).
UnitedHealth Group. 2006. “UnitedHealth Group Reports Record Third Quarter Net Earnings of $0.79 per share.” News Release, October 19.
United States Government Accountability Office (GAO). 2006a. “Federal Employees Health Benefits Program: First-Year Experience with High-Deductible Health Plans and Health Savings Accounts.” GAO-06-271 (January).
_——-. 2006b. “Consumer Directed Health Plans: Early Enrollee Experiences with Health Savings Accounts and Eligible Health Plans.” GAO 06-798 (August).
White, Joseph. 1995b. “Medical Savings Accounts: Fact vs. Fiction.” Brookings Institution Working Paper.