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 – A SKEPTICAL VIEW
Abstract
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.
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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 1/6
th 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?
HDHPs PUT PRESSURE ON PRIMARY CARE
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.
IS IT WISE TO CHOOSE PRIMARY CARE AS A TARGET FOR COST
SAVINGS?
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.
DOES MARKET THEORY MAKE SENSE IN PRIMARY 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.
HDHPs’ POSSIBLE DELETERIOUS EFFECTS ON QUALITY OF CARE
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.
TWO INDIRECT EFFECTS OF HDHPs ON THE HEALTH CARE
SYSTEM
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, ADVERSE SELECTION, AND EFFECT ON THOSE WHO ARE
SICK
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.
HDHPs’ IMPLICATIONS FOR SOCIAL PHILOSOPHY AND FAIRNESS
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.
CONCLUSION
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.
[iii] Employer
Health Benefits 2012, op. cit.
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