Tuesday, December 25, 2012

Campaign message vs. campaign mechanics

There are so many ways to look at elections.

The most direct and na├»ve way is to say that the message of one candidate was better accepted by the electorate, resulting in a mandate, as in, “elections have consequences.”  Tax the 1%, that’s what the electorate voted for.

Then there are demographics.  We are no longer a WASP nation, and not only are there more minorities, but they now have the temerity to vote.  So policies that are sensitive to the wishes and interests of these groups are justified.

And then there are the election technicalities.  How are the campaigns organized, how effective are they?  Increasingly, campaigns are unbelievably technological and organized.  See today’s Boston Globe: http://www.boston.com/news/politics/2012/president/2012/12/23/the-story-behind-mitt-romney-loss-the-presidential-campaign-president-obama/2QWkUB9pJgVIi1mAcIhQjL/story.html

Obama made wonderful electoral decisions; Romney, not so much.  I agree that running an election is a relevant test for running a country, not completely, but not irrelevant.  But where does that leave us in judging “a mandate?”  If you were good at running an organization that could collect money and deploy it skillfully, what does that say about taxing the 1%?  It would seem, not that much.

On the other hand, if you don't have a message that resonates, you can't get the enthusiasm to run a campaign, which still largely utilizes volunteers.  And the attention the campaigns focus on getting the right message at the right time to the right people speaks to the importance of the basic message, and the particulars.

So, in the end, even if the technical expertise in running a campaign seems so predominant a factor, I guess the idea of a mandate for the main themes of a campaign are at least allowed to be pursued.  But add together the technical aspects of the campaign and how close the division of the vote really is – 51% to 48% is “decisive” – and you have to say, leadership counts, boldness counts, and elections are permissive.

Budd Shenkin

Monday, December 24, 2012

High Deductible Health Plans - A Skeptical View

OK, readers - a 4,000 word post on health policy.  High Deductible Health Plans - HDHPs - are invading the health care system with few voices raised against them.  I think they are just what we don't need, yet they are accepted without real questioning.  Why?  Because they are politically convenient, as I explain in the article.  And who do they screw?  Just the same "middle class" that we are all so, rightfully, concerned about.  Yet the Bipartison Policy Center and so many more politically powerful groups, not to mention health insurance companies, accept them without question.  Fie upon them!!

I believe that this article is the only article critical of HDHPs that approach them in a comprehensive manner.  I wish it could be published - but Health Affairs turned it down as not presenting an original point of view, saying that everything I say is already known.  Well, maybe so, by the cognoscenti, but where is it all put together, editors?  I've never been very good at being aggressive about getting things published.

OK - here it is.



High Deductible Health Plans have been growing in prominence at rapid rate.  They are attractive because they reduce costs to employers and are simple to introduce.  As health policy, however, HDHPs are very problematic.  Primary care is singled out for attack, when national policy requires the opposite.  Access to care and financial protection are compromised for the less wealthy, quality of care declines, and adverse selection is encouraged.  Instead of being protected, the chronically ill and those with less financial means suffer financial penalties.  As HDHPs penetrate ever more deeply into the fabric of American health care, basic policy decisions need to be made as to their place in the system, since they pose a severe challenge to our basic social philosophy of health care.

No one doubts the inefficiency of the American health care system, and no one doubts the need for reform to reduce costs.  The modern “Triple Aim” of health care policy is to reduce costs, improve quality, and improve the health status of the general population. But reform is hard because most schemes require multiple players to cooperate in complex plans, and many need legislation to enact.  Moreover, since power is diffuse in our system, most stakeholders have been able to block reforms that would gore their own ox. 
One reform that has been able to gain traction is the High Deductible Health Plan (HDHP), also known as the Consumer Directed Health Plan (CDHP).  As a business strategy, HDHPs have proved remarkably attractive.  One report found that 31% of employers offered HDHPs in 2011 while another found that 59% of major employers provided an HDHP option in 2012.[i] [ii]   In 2011 perhaps 7% of the United States population was enrolled in an HDHP.  This translates to an enrollment of 15.8 million adults aged 21-64 and over 5 million children and youth aged 0-20.  Recently there has been particularly vigorous growth in HDHPs in small businesses with relatively low paid workers.[iii]  Further growth seems inevitable, since HDHP’s will be offered on the Health Insurance Exchanges mandated by the Patient Protection and Affordable Care Act.
Why are HDHPs attractive?
Why have HDHPs proliferated?  Their most obvious attraction is political, in the sense that the two most powerful parties in the health insurance purchasing transaction, employers and insurance companies, are favored.  As health care costs rise, employers can maintain health insurance support for their employees at a reduced cost and thus remain competitive, and health insurance companies are able to maintain the accounts, rather than seeing the employers drop coverage.  The least powerful party, employees, is left with increased costs in the form of heightened out-of-pocket, first dollar expenditures.  In addition, the benefit reduction can be masked to many of the employees, since the increased costs to them are not certain but only probabilistic, and thus harder to calculate and anticipate.

HDHPs are also attractive in terms of political-economic theory.  Placing consumers with “skin in the game” is congenial to the market-friendly American mentality.

Moreover, HDHPs are practical to introduce.  They are simple.  They can be enacted without cooperation of other health system participants, and their enabling legislation was non-controversial.

The legal requirement that HDHPs offer basic preventive visits, immunizations and screenings free of deductible or copay requirements is also simple.  It is true that the provisions for tax-free Health Reimbursement Arrangements (HRA) or a Health Savings Accounts (HSA) were more complicated.  But since they act to soften the financial load to patients and give them financial incentives to self-ration services, they were non-controversial.

HDHPs also appear to be familiar. The current requirement for an HDHP is a deductible of at least $1,200 for individuals or $2,400 for families, and a total annual out-of-pocket maximum of $6,050 for individuals and $12,100 for families.[iv]  While these levels of patient expenditure are much higher than those of conventional policies, the differences are not of kind, but only of degree.  The changes thus appear to be only incremental, which makes them easier to accept.  Only the HSAs and HRAs are novel.

Thus, HDHPs have been successful in avoiding the hazards of many proposed reforms.  They require few parties to institute, the most severely affected party is the least powerful, and the reassuring familiarity of their operational mechanisms induces acquiescence. 

HDHPs do reduce total costs

As economic theory predicts, since HDHPs present patients with a higher marginal cost for seeking first-dollar services, the subscribers reduce their consumption of those services.  They visit their clinicians for fewer episodes of illness, make fewer visits within an illness episode, are prescribed generic rather than branded drugs more often than other patients, make fewer specialist visits, and are less frequently hospitalized.[v] [vi] 

We do not know what happens to costs in the long run, but in the short run, total costs generated by these patients are reduced.  In fact, Haviland et al. have predicted that if enrollment in HDHPs expanded to 50% of employees, the savings in total costs could amount to 5% of total health care costs, or $57 billion in the first year.[vii]  This would be about 1/6th of the total savings some analysts estimate would be available if waste were comprehensively cleared from the system.[viii]

With such potential savings on the table, health policy analysts must take note.  Even though HDHPs began as the path offering the least political resistance to premium cost reduction, is it possible that this piecemeal solution could become an important component of reform of the American health care system?  Or do HDHPs affect the health system coherence, access, quality, and equity in ways that lead us to reject them as poor substitutes for more difficult reforms that save costs by better design and increased efficiency?  How do HDHPs stack up against the Triple Aim?


By the very nature of a deductible, HDHPs single out initial care for abstemious utilization.  “Initial care” would be mostly primary care, with secondary targets the services that flow from primary care visits – tests, imaging services, medications, initial office services, and the first day of hospitalization.  By the same token, HDHPs perpetuate the support of conventional insurance policies for utilization at the higher levels – hospitalizations, procedures, ICU care, etc.

Under an HDHP, the patient must first decide if a complaint warrants the full cost of an office visit, now more expensive than under a conventional policy.  In addition, experienced patients will anticipate that they will be confronted by further vexing and anxiety-laden decisions of whether or not to follow through on the expensive recommendations of their clinician for subsequent specialist visits, tests, studies, medications, follow up visits, or even hospitalization.  The sum total of these cost expectations and difficult decisions puts psychological pressure on the patient to exercise denial and procrastination, rather than to take care of a worrisome condition expeditiously.

If the HDHP patient decides not to ignore the condition, her or she might choose to use the internet to seek information or to make his or her own diagnosis.  While open information is a very good thing, if the search goes beyond simple information retrieval, it is left to the patient’s judgment to decide on self-diagnosis vs. professional diagnosis.  The threat of poorer quality health care with self-diagnosis is real and non-trivial.

The next step up in the patient cost-savings strategy is to call the primary care office for advice at no charge, since most offices still charge patients only for office visits, and since most health insurance policies still do not honor telephone charges.  While such calls can be appropriate, clinical offices report that HDHP patients typically use them much more than those with conventional insurance.  To the extent that the telephone call actually substitutes for what would have been a visit, the patient gains financially, system efficiency gains, but primary care office overhead increases and practice income declines in the fee-for-service environment.   In no case does increased telephone care actually increase medical quality, and sometimes it decreases it.

A third HDHP patient strategy involves bundling the preventive visit.  Since preventive visits are free but sick visits are subject to full out-of-pocket payments, patients logically tend to save up all their ills to be addressed at well visits.  This understandable cost-sparing tactic, however, compromises the quality of the visit.  Both well-care and sick-care visits require time.  The guidelines for preventive visits call for long and detailed assessments, so comprehensive, in fact, that it is very hard for practitioners to complete them in the time allotted.  Sick visits also take time if justice is to be done to caring for the illness thoroughly.  If the visits are to be combined, one or the other or both will suffer.  And again, as with increased telephone care, primary care practice financial support will suffer.  If the visits are in fact combined, according to CPT coding rules, the clinician is justified in charging for two separate visits, one sick and one well.  But the patients will then be asked to pay for the sick visit out of pocket, which often outrages them.  If the clinician chooses to perform only one or the other visit at a time and ask the patient to return for the other visit at a subsequent appointment, the patient is often not understanding of the dilemma.  So once again, issues of payment come between the primary care clinician and the patient to the detriment of both. 

If the patient does make a visit for an illness, the next point of contention is deciding on further medical steps, all of which will entail significant further expense for the HDHP patient.  The patient now experiences a replay of the decision whether or not to visit the office, but this time the clinician is involved.  The incentive of the clinician to cover medical liability by ordering and referring fully is balanced by the financial consequences to the patient.  While weighing this balance is a good thing; it is not clear if financial pain to the patient is the best incentive to apply to this process.  Since the clinician is the most knowledgeable party, the well-known clinician scorecards of managed care surveillance would seem to be more appropriate.

While the above examples are obvious and predictable, a less obvious HDHP consequence is the havoc HDHPs wreck in the primary care office in the simple administration of the payment transaction.  The status of the deductible is typically unknown at the time of the visit, and the functioning of specific HRAs and HSAs are often mysterious to both patient and staff.  Billing and collecting thus becomes very difficult.  Here is the process:

      • The office bill is generated
      • The status of payment due is unknown at the time of service
        • The in-network payment due, as adjusted by the insurer, may well not be known
        • The deductible status of the patient will be unknown
      • The bill, therefore, is sent to the insurance company
      • The insurance company calculates the bill, adjusts downward to the allowable fees, applies the deductible, and sends the Explanation of Benefits to the medical office explaining that the office needs to collect from the patient
      • The office sends a bill for that insurance-generated amount to the patient
      • The patient may or may not pay, often delays and/or questions the bill, which is difficult to understand
      • The billing cycle continues with more billing and constant office staff activities

In sum, then, HDHPs lead patients to adopt cost-savings strategies that may save some costs appropriately, but may interfere with quality.  HDHPs certainly visit more anxiety upon the patient deciding between medical care and the worry of illness.  HDHPs severely strain primary care office processes and lead to increased overhead and bad debt. 

Perhaps most importantly, there is no aspect of primary care more prized by clinicians than the trusting relationship between them and their patients.  Whereas traditional first-dollar coverage buffers the inherent financial strain of this relationship, HDHPs exacerbate it.  As HDHPs become more prominent in the health insurance landscape, primary care offices increasingly view them as the bane of their existence.


Even if HDHPs wreck havoc with the primary care office, that could be a warranted approach if the primary care office were a profligate waster of resources, and thus in need of reform.  Is that the case?

In fact, however, primary care has never been cited as the source of excessive utilization that needs to be reformed.  Primary care is the biggest bargain of our medical care system, if there is one.  Primary care clinician income is half or less compared to procedural specialists.[ix]  The system as a whole spends less on primary care than on procedurally-based specialty care, and far less than hospitals.  The big fish in health care costs are hospitals; oligopolistic groupings of hospitals and specialists; end of life care; high tech care; inefficient purchasing; inflated prices for purchasing, studies, pharmaceuticals, etc.[x]  Targeting primary care is fishing for minnows.

Further, most health care analysts believe that the most fundamental weakness of the American health care system is too much specialty care and not enough primary care.[xi]  Looking specifically at how high costs are generated, many have found that it is a small group of patients that generate the most costs: “Nearly two-thirds of health care costs are concentrated in 10% of patients, so to control costs, the focus needs to be on these patients, not the 50% of the population that is relatively healthy, and uses just 3% of the health care dollar.”[xii]  For these patients more primary care, not less, will lead to decreased costs.[xiii] 

The most promising current effort to improve primary care services and at the same time to decrease total costs, calls for increasing resources in primary care with the Patient Centered Medical Home (PCMH).[xiv]  The PCMH is essentially a strengthened office with highly personal care, more nurse outreach, an emphasis on prevention and patient population registries, attention to self-care, and guidance through the medical care system. The PCMH can target the high utilizers and prevent ER visits and hospitalizations through enhanced interventions.  The theory of the PCMH is to activate the primary care office, which can then activate the patient in a direction informed their professional knowledge, in contrast to the HDHP theory of activating the patient directly with whatever knowledge they can muster on their own .  The PCMH takes the Triple Aim of health care policy seriously.  If the idea of PCMH is correct, then the idea of HDHPs, which would discourage primary care visits and economize at the expense of primary care offices, must be incorrect.

In sum, there are few worse paths that health care policy could follow than discouraging primary care, yet that is the effect of HDHPs.  Cutting costs is essential, but in doing so it is crucial not to sacrifice this endangered and vitally important segment of care.


Using the market mechanism is always appealing, because once established, the market functions automatically and without the need for conscious regulation and design.  There is serious question, however, if the market mechanism can be applied to medical care at the level of the patient.  To act well as market participants, consumers need adequate knowledge and information to make intelligent choices.  Medical knowledge is so specialized that many doubt the applicability of the market for medical care on that basis alone.[xv]  The complexities of medicine and the medical care system can be overwhelming to the lay-person, urgent situations are not compatible with “careful shopping,” and the emotional upset caused by illness often compromises rationality in making a choice.

Studies confirm that some sets of patients consistently make misjudgments in their medical choices.  For instance, while HDHP patients incur fewer medical costs for illness care, they also have lower rates of well visits, immunizations, and preventive screens than those in traditional plans, despite the absence of out of pocket costs.[xvi]  HDHP patients do not even understand their policies enough to realize that preventive care is free to them.[xvii]  Patients are notoriously poor at judging quality; for instance, they frequently equate high cost care with high quality care.[xviii]  One of the most important functions of the primary care practitioner, in fact, is to guide the patient and to help the patient choose.  Thus, it seems counterintuitive to encourage lay people not to use the professional knowledge and judgment of a primary care practitioner, particularly when a primary care visit is relatively inexpensive.

On the other hand, it would be wrong to over-generalize.  Some patients with health care understanding and good reasoning ability will make good choices that could be cost saving without compromising quality.  Likewise, despite having a significant deductible, wealthier patients will be less deterred than others from seeking early care, and thus will sometimes receive early diagnosis of a significant health condition, or will receive the comfort of a reassuring visit that confirms basic good health.  Indeed, these are precisely the patients who have historically enrolled preferentially in HDHPs, although that trend is changing.[xix]  So the idea of some patients sometimes fending for themselves can be valid in some circumstances.

Shopping for price, however, finds virtually all patients in the same boat.  Finding cheaper care is difficult for everyone.  For one thing, price information on procedures and visits is generally not available, as numerous accounts attest.[xx]  Moreover, since a visit can lead to other expenses, neither a patient nor an office can usually predict the total cost.  The best current efforts to enable patients to be better shoppers concentrate on higher cost services.[xxi]  In primary care, however, Fuchs comment is the most valid: “The idea of sick patients shopping for the lowest-price medical care … is a fantasy.” [xxii]

In sum, using the patient as a sapient shopper in the primary care marketplace is not a strong current possibility.


Despite the great strides made in recent decades to define and improve quality of care, quality measurement in specific circumstances still remains a formidable challenge.  Studies are expensive and difficult to mount, and when they are conducted, they can capture only a small portion of quality of care in all its aspects, and can virtually never capture long-term effects.  Very few studies have attempted to capture quality of care under the condition of HDHP insurance.  Objective data is thus lacking.

Nonetheless, it should be clear a priori that HDHPs pose many implications for quality of care.  One of the few aspects of quality that has been measured is preventive care.  Under HDHPs, preventive visits decline and basic quality measures, such as screening tests administered and immunization rates, suffer.  We also know that patient decisions in a medical care marketplace are often not well informed.  Continuity of care and the doctor/patient relationship suffer as primary care visits are discouraged.  HDHPs lead to delayed or absent primary care visits; if it is true that early detection can protect health and save lives, then HDHPs are hazardous to the health of the subscribers.  Overall, it is hard to imagine that quality of care is unaffected by HDHPs.  There is no recorded instance where restricting primary care access has led to improved quality of care.


American medical manpower distribution is already dysfunctionally skewed toward specialties and becoming more so.[xxiii]  Two prime reasons for this skew are the imbalance of specialty/primary incomes and the difficulty of running primary care offices.  By targeting primary care for economies, and by making the primary care office much harder to run and increasing both overhead and bad debt, HDHPs will further discourage medical school graduates from entering primary care, and the manpower skew will be exacerbated.

Another overlooked possible effect of HDHPs is on innovation.  While we are used to and welcome high tech innovations for specialties and procedures, innovations in primary care could benefit from innovations as well, beginning with the PCMH, and extending to preventive screenings, proactive health promoting activities, and more.  Innovations, however, migrate to where the money is.  The more HDHPs proliferate, the more innovation will be directed to higher-end higher-cost specialties and hospitals, and ever less to cost-saving and health-promoting primary care.


HDHPs are a virtual recipe for adverse selection.  When given a choice, patients who think they will not be using services because of good health prospects or a disinclination to use medical resources, will be the ones to choose HDHPs.  HDHP’s will also preferentially attract patients who could weather a surprising yearly bill of $6,000 or $12,000.  Those remaining in conventional polices where there is a choice, then, will tend to be those with chronic diseases, those fearful of impending poor health, and those with fewer means to withstand a large health care bill.  As a result, with the lower-cost and risk-tolerant cream of the crop removed, premiums for conventional policies will rise, to the detriment of the ill and the less well off.

Increasingly, many patients have no choice and must accept an HDHP policy.  Many of them will be low or middle-income families living near the margin of economic viability.  If they have chronic diseases or unexpected illnesses, the financial consequences of HDHPs for them will in many cases be disastrous. 


In the end, a country needs to choose among alternatives.  It is seductive to some to believe that the concept of freedom compels us to allow the healthy, well educated, and financially stable to forego excess insurance contributions, and to use their abilities, knowledge, and wealth to their advantage. It is also seductive to believe that somehow a superior social, educational, and economic situation has been earned, and the fruits of that success should be realized in superior health care choices.  One needs to acknowledge, however, the consequences of such a choice.  HDHPs result in financial harm to the less healthy and the less advantaged.  Indeed, HDHPs can be seen as a poor to rich, sick to well transfer payment.

It would be one thing to make the choice to allow HDHPs if those favored – the more healthy, more knowledgeable, more wealthy – had joined the group by merit.  It is increasingly clear, however, that to be well and well off is highly related to the luck of one’s birth and genetic makeup, rather than entirely a result of specific merit.[xxiv]  Of course, luck is not always at work – obese smokers and heavy drinkers, for instance, cannot attribute their bad health experience entirely to “bad luck.”  Nonetheless, good or ill fortune is often at the root of illness and the need to seek care.  This is especially true with children, who cannot easily be blamed for their illnesses.  It is one thing to embrace a philosophy of rewarding merit; it is quite another to embrace one of rewarding luck. 

To what extent are we as a nation willing to endorse unequal access to health care?  We might well countenance financial resources dictating the choice of a semi-private vs. a private hospital room.  But it is very different to decide that a worried high-income family with a sick child can seek care with little financial impediment, a poor family on Medicaid can do the same, but a middle-income family will face a significant financial barrier for that very same primary care visit.  And it is yet another unpalatable decision to require a family with a chronic illness to pay higher premiums and/or more out of pocket than a family blessed with good health.

These are clearly the philosophic stakes as we imbed HDHPs more deeply into our health care system. 


HDHPs can lower costs for purchasers, lead subscribers to be more abstemious consumers of primary care, and even lower costs for the health care system as a whole.  Nonetheless, by targeting primary care, HDHPs look for savings in the wrong places.  HDHPs undercut the viability of primary care, whereas system reform would best be served by strengthening primary care. They penalize the less-well, the less-well educated, and the less-well off by increasing costs to them and promoting adverse selection.  They likely lead to lower quality of care.  HDHPs aim at only the first component of the Triple Aim -- decreased costs --neglecting or negatively impacting quality and the health of the general population.

With all these negatives, the nation would be well advised to examine the proliferation of HDHPs more critically, and adopt instead alternative cost-savings approaches that strike at the highest cost areas and areas of true waste and inefficiency.[xxv]  Even though alternative schemes are more difficult than HDHPs to enact, most will save costs without decreasing quality and without further distorting the organization of health care. 

It would be best if HDHPs were removed from the menu of health insurance choices.  Failing that, they need to be wholly revised so that primary care is not discouraged, adverse selection does not occur, and the advantaged are not favored over the disadvantaged.  It is not immediately clear how one could do this.

[i] Employer Health Benefits 2011 Annual Survey, Kaiser Family Foundation – accessed at http://ehbs.kff.org/?page=charts&id=2&sn=15&p=1 on August 13, 2012
[ii] Employer Health Benefits 2012 Annual Survey Kaiser/Health Research and Educational Trust Study, accessed at http://ehbs.kff.org/pdf/2012/8345.pdf on December 12, 2012.
[iii] Employer Health Benefits 2012, op. cit.
[iv] Mulvey J. Health Savings Accounts: Overview of Rules for 2012. December 20, 2011. Congressional Research Service 7-5700. www.crs.gov. RL33257
[v] Haviland AM, Sood N. McDevitt RD, Marquis MS. The effects of consumer-directed health plans on episodes of health care; Forum for Health Economics & Policy 2011:14:issue 2, Article 9:1-26.
[vi] Haviland AM, Sood N. McDevitt RD, Marquis MS. How do consumer-directed health plans affect vulnerable populations?; Forum for Health Economics & Policy 2011;14:issue 2, Article 3:1-23.
[vii] Haviland AM, Marquis MS, McDevitt RD, Sood N. Growth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annually: Health Affairs 2012; 31:1009-1014.
[viii] Cutler D.  How health care reform must bend the cost curve: Health Affairs 2010; 29.6:1131-1135.
[ix] Bodenheimer T.  Primary care – will it survive?  NEJM 2006;355:861-864.
[x] Reducing waste in health care.  Health Policy Brief, Health Affairs, December 13, 2012.  Accessed December 13, 2012 at http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82
[xi] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health.  Milbank Quarterly 2005;83:457-502.
[xii] Emanuel EJ.  Why Accountable Care Organizations are not 1990’s managed care redux.  JAMA.  2012; 307 (21):2263-2264.
[xiii] Gawande A.  The hot spotters.  The New Yorker.  January 24, 2011.
[xiv] Landon BE Gill JM, Antonelli RC, Rich EC.  Prospects for rebuilding primary care using the patient-centered medical home.  Health  Aff (Millwood), 2010;29(5):827-34.
[xv]Retchin SM. Overcoming information asymmetry in consumer-directed health plans. American Journal of Managed Care 13: 173-176, 2007.
[xvi] Haviland et al. Health Affairs, op. cit.
[xvii] Reed ME, Graetz I, Fung V, Newhouse JP, Hsu J.  In consumer-directed health plans, a majority of patients were unaware of free or low-cost preventive care.  Health Affairs, 31, no.12 (2012):2641-2648
[xviii] Hibbard JH, Green J, Sofaer S. et al. An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care. Health Affairs 2012; 31: 560-568/
[xix] Haviland et al., Health Affairs, op. cit.
[xx] Bebinger M.  How Much For An MRI? $500? $5,000? A Reporter Struggles To Find Out.  Kaiser Health News, accessed December 12, 2012 at http://www.kaiserhealthnews.org/Stories/2012/December/09/mri-cost-price-comparison-health-insurance.aspx
[xxi] Robinson JC, MacPherson K.  Payers test reference pricing and centers of excellence to steer patients to low-price and high-quality providers.  Health Affairs 2012;31 (9):2028-2035.
[xxii] Fuchs VR.  Eliminating “Waste” in health care.  JAMA 2012;302:2481-2.
[xxiii] Iglehart JK.  Primary care: light at the end of the tunnel?  N Engl J Med 2012; 366:2144-2146.
[xxiv] Zakaria F.  The downward path of upward mobility.  November 9, 2011, The Washington Post.
[xxv] Emanuel E, Tanden N, Altman S, Armstrong S, et al.  A systemic approach to containing health care spending, NEJM 2012;367:949:954.