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Consumerism

Competition In Health Care: Its Evolution Over The Past Decade

Abstract

 
Understanding the roller-coaster experience with the use of market forces in health care over the past ten years provides important context for discussions of likely future developments in the nature of competition. The period began with acceptance of managed care transforming the organization of medical care delivery and proceeded to a period in which many of the changes were reversed. The vision of integrated delivery has now been replaced with a vision of a more active role for consumers. But the greatest potential for a larger role for consumers lies in mechanisms that apply competitive pressure on providers to improve the quality of care that they provide and reduce their costs.

Understanding the experience of the past ten years provides important context for understanding the nature of competition today and its potential to evolve in different directions in the future. This paper begins with observations on competition in 1995, which is slightly past what one might call the peak of managed care’s influence. It goes on to describe the market and policy responses to the backlash against managed care and then to competition in the post–managed care era; it concludes with some perspectives on the likely evolution of competition over the next few years.

Competition In 1995

Top Competition In 1995 Backlash Against Managed Care Markets Under Looser Managed... Recent Market Dynamics Potential Market Developments NOTES

 
Competition in 1995 was highly influenced by the critical mass that managed care had achieved by that point. According to KPMG Peat Marwick’s 1996 survey of employers, 73 percent of those obtaining coverage through employment were in managed care plans, compared with 27 percent eight years earlier.² Health maintenance organizations (HMOs) were the most popular plan type, accounting for 31 percent of the market.

Benefit structure. The benefit structure in managed care plans included far less in the way of financial incentives for patients than had been the norm in traditional insurance plans. This reflected a managed care philosophy that consumers should not be called on to limit their use of services because of ability to pay. Instead, professionals—either the patient’s physician, with incentives other than fee-for-service, or clinical staff of the health plan—should take responsibility for limiting services that have low value.

Differences among plans. Leading employers that operated in multiple locations, such as General Electric (GE), often performed careful assessments of HMOs in each community in which they operated, to choose those most appropriate to offer employees. They and many other large employers offered a broad choice of HMOs and other plan types. Differences among plans were often significant, especially compared with today. Because provider networks were selective, enrolling in a particular HMO affected which hospitals and physicians a consumer could use with payment from the health plan. Health plans also used different tools to manage use.

Insurance industry. The health insurance industry was undergoing a period of aggressive expansion in 1995. The industry was highly profitable at the time, mostly because cost trends came in below expectations at the time that premiums were set, for several consecutive years.

Many insurers were entering new markets in 1995, often spurred by the belief that this would be the last opportunity to do so. Entry typically involved purchasing a relatively small local plan and expanding it, often through setting premiums low in relation to costs. The rapidly growing Medicare plan market was considered the most attractive segment at the time. This likely occurred because payments from Medicare were pegged to costs in the traditional program, which were increasing at a higher rate than costs for managed care plans.

Managed care transformed the health insurance industry. Companies that were most successful in offering managed care products, especially HMOs, were those that had started up as local or regional HMOs. Traditional insurers tended not to be good at this, and one (Aetna) later acquired a large regional HMO (U.S. HealthCare) and put the HMO executives in charge of the entire operation. UnitedHealthcare, which started as an HMO company, later acquired a large traditional insurer to expand its reach. Blue Cross and Blue Shield (BCBS) plans lost market share to other insurers, although they continued to be the dominant insurers in many markets.

Hospitals. Many hospitals entered the insurance business around this time. For some, the main attraction was the very large margins being earned by insurers at the time. For others, this was part of a broader strategy to create an integrated delivery system (IDS) through an insurance product that directed patients to the hospital and its physicians.

Plans’ provider networks were selective enough to gain payment rate concessions from physicians and hospitals. This contributed greatly to the slowing of cost trends. For example, the trend of hospital prices to payers other than Medicare and Medicaid declined from a 4 percent increase in 1994 to a 1.8 percent increase in 1996.³ Data on transaction prices for physician services began to be gathered a year later but show the trend declining from 3.1 percent in 1995 to 0.7 percent in 1996.

Coping with managed care was a key issue for hospital leaders. One of hospitals’ main responses to the growth of managed care was consolidation. Hospitals correctly perceived that by merging with others in the same community, they would increase their leverage with health plans. The U.S. Federal Trade Commission (FTC) challenged some of these mergers as anticompetitive, but the hospitals prevailed in court in every case during this period. Our interviews noted broad awareness of these cases, presumably emboldening consolidation strategies.

Two factors accelerated the trend toward hospital mergers. One was the phenomenon of Columbia/HCA, the acquisition-minded for-profit hospital system. Many hospitals feared Columbia/HCA as a potential competitor in their markets and took action to prevent this, such as acquiring a hospital that might otherwise be acquired by Columbia/HCA. The second was the lore that only hospital systems could compete in the new world of managed care and that independent hospitals were doomed. This undoubtedly led many hospitals with solid market positions to seek a merger partner.

Nevertheless, the merger trend proceeded slowly, and many hospitals nevertheless suffered from weak bargaining positions vis-à-vis health plans. The ratio of revenues received from private payers to costs declined from 1.29 in 1993 to 1.14 in 1998.⁴ Hospitals were concerned about exclusion from a plan’s network if they did not come to agreement with the plan on payment rates. The decline in hospital use that resulted from management of care also meant that most hospitals had excess capacity, leading them to be more eager to avoid exclusion from networks.

Hospitals pursued a host of strategies to align the interests of their medical staffs more closely with their own. Many acquired primary care practices—a strategy that rarely succeeded, often because physician productivity was much lower than when physicians owned the practices. Hospitals created physician-hospital organizations (PHOs), which attempted to negotiate with health plans on behalf of hospitals and physicians together, and management services organizations (MSOs), which provided management services to physician practices. Most of these organizations probably did not achieve enough to pay the additional overhead. But even if they did work, the subsequent decline in risk contracting removed much of their potential.

Physician practices. Physician practices also responded vigorously to the dynamics of a marketplace dominated by managed care. Physicians in many areas formed independent practice associations (IPAs), which typically contracted with health plans on a risk basis while paying physicians fee-for-service (FFS), using utilization management tools to limit use of services. Respondents reported increased rates of formation of multi- and single-specialty groups, including those limited to primary care. Although having more bargaining power with health plans was a general consideration, in Southern California, physicians were very eager to achieve the organizational size needed to contract with plans on a capitated basis and have the utilization management delegated to physicians.

With the exception of some single-specialty groups that accounted for a sizable share of the specialists in a community, physicians had even weaker leverage with health plans than hospitals did. Although certain prominent hospitals had some leverage on the basis of their reputation and importance, no single physician had such importance to be able to command a higher fee schedule conversion factor than others. Negotiation of prices between plans and physicians was likely facilitated by the substantial adoption by managed care plans of the Medicare resource-based relative value scale. It meant that negotiation did not need to involve more than a single number—a conversion factor.

What was particularly striking about the competitive situation in 1995 was the broad belief that IDSs were the wave of the future. The notion was that individual consumers, through choosing a health plan, would commit themselves to a delivery system, which would have the financial incentives and would develop a culture to manage the care of its enrollees according to principles of population health. Although Kaiser Permanente had had success with its integrated model for decades, many believed that they could achieve much of what Kaiser had accomplished with a looser and less formal delivery system. Much of the organizational change during the period was driven by the idea that integrated delivery would in time form the core of the health care system.

The Clinton plan. Although often referred to today as a highly regulatory proposal, many respondents at the time viewed the Clinton plan as an important catalyst for the development of managed care and integrated delivery. They anticipated that the more widespread choice of health plans, through purchasing cooperatives, would accelerate the already rapid growth of managed care products.

Backlash Against Managed Care

Top Competition In 1995 Backlash Against Managed Care Markets Under Looser Managed... Recent Market Dynamics Potential Market Developments NOTES

 
Physicians’ and consumers’ unhappiness with managed care had profound effects on health care markets—both directly, through changes in insurance products, and indirectly, through public policy changes. I believe that a key factor in this backlash was the rapid shift in enrollment from traditional insurance plans into managed care, with many of the new enrollees not joining voluntarily.⁵ During the long history of prepaid group practice, most who enrolled in a group- or staff-model HMO chose their plan over traditional insurance, so they began positively disposed and could change plans if they decided they had made a mistake. Put in different terms, traditionally, people who enrolled in HMOs thought they had something to gain. But many who enrolled for the first time during the early or mid-1990s saw such enrollment as a loss—either losing their traditional option or enrolling in managed care to avoid having to pay more.

Consumers were concerned about the possibility of unwarranted restrictions on their care. Physicians, who objected to both restrictions on care and payment rate reductions, clearly played a role in consumers’ dislike of managed care. The media also played an important role, with numerous stories about people not getting the care they needed because of denials by their HMOs. In policy discussions, no doubt influenced by polling, provider choice appeared to be a frequent topic. This may have come from consumers’ strong trust in their own physicians—that as long as they could choose a physician they trusted, they would have an advocate to avoid unwarranted restrictions on care.

The backlash against managed care led to vigorous—and parallel—responses by both the market and public policy. Employers responded by altering the managed care products provided to employees, making them less restrictive. Times had changed since "C-suite" executives had focused on health benefits and shifted employees toward managed care plans. Profitability had returned, and labor markets were much tighter. Also, some of the cost implications of less-restrictive products were not visible to individual employers, since plans’ leverage with providers depends on the restrictiveness of products at the market level.

Employers loosened many of the dimensions of managed care. They provided more preferred provider organization (PPO) options. They insisted on broader provider networks. They dropped authorization requirements to admit patients to hospitals, refer to specialists, or order expensive diagnostic or therapeutic procedures. They introduced HMO products that permitted access to specialists without a primary care referral. These changes did not happen all at once. The broadening of networks was already occurring in 1995. But the biggest changes concerning authorization requirements did not come until late 1999, when UnitedHealthcare announced its change with great fanfare, and other plans followed suit.

Many state legislatures enacted "patients’ bills of rights." These provisions tended to specify appeals procedures for enrollees, minimum hospital stays for procedures such as childbirth, direct access to obstetrician-gynecologists, rules on the adequacy of a provider network, and, in some states, ability to sue health plans over decisions to restrict payment for care. The federal government debated similar legislation for many years but was unable to come to an agreement. During the later years of the federal debate, many observers noted that many of the provisions in the legislation had already become the norm in markets throughout the country, with patients’ ability to sue health plans being seen as the most important, and most contentious, provision of the legislation.

Markets Under Looser Managed Care

Top Competition In 1995 Backlash Against Managed Care Markets Under Looser Managed... Recent Market Dynamics Potential Market Developments NOTES

 
I would characterize the late 1990s and early years of the current decade as a time in which restrictive managed care models had been unwound, but the next regime—consumer-driven health care—had not been established. For example, financial incentives for providers had been mostly abandoned, but financial incentives for consumers had not yet begun. Put another way, the managed care benefit structure stayed in place for a few years after the tools of managed care had been diminished.

Reversal of integrated delivery. Many of the nascent steps toward integrated delivery were reversed during this period. The integration of health insurance with provider systems became much less attractive with requirements for broad networks. So although a hospital’s health plan might have limited its network to the hospital system and its affiliated physicians at one point, now it had to include many of its competitors as well. This undermined a key basis for integration.

Hospital-owned health plans. Parenthetically, even though hospital-owned health plans had become less viable strategically (and had problems even before broader networks), they were not the unvarnished failure that some other hospital strategies, such as acquiring primary care physician practices, had been. Some hospital-owned health plans were profitable and have continued or were sold to raise capital for hospital expansion—the plan being more valuable to a large insurer than it was to the hospital. For example, in the Seattle market, Providence-Seattle Hospital sold its plan to Regence Blue Shield in the late 1990s.

Abandonment of capitation. As the use of capitation declined, many combinations of hospitals and physicians lost their reason for being. Capitation appeared to have been abandoned by both providers and health plans. Providers abandoned it because they had lost money. Losses probably resulted most often from failure to set up an effective infrastructure to manage utilization or unrealistic expectations about potential effectiveness. Plans often abandoned capitation because they believed that their tools to manage utilization were more effective than providers’ efforts.

As capitation became less widely used, it became clearer that many of the attempts of hospitals and physicians to align their interests had not involved much more than coming together to negotiate contracts with insurers. Little had been put in place to motivate or support physicians practicing differently. An irony is that now—in 2005—we are starting to see creativity in hospitals and physicians working together more effectively.⁶

Primary care physicians versus specialists. In the mid-1990s many noted how the position of primary care physicians had improved in relation to that of specialists. Many HMOs used gatekeeper models, which required patients to see a primary care physician to be referred to specialists. This was sometimes combined with a need for the primary care physician to obtain authorization from the health plan for the referral. This led to increasing demand for primary care physicians, higher compensation, and a practice model closer to the long-time vision of primary care leaders. But with the decline in the gatekeeper model and elimination of authorization requirements, this trend quickly reversed. Indeed, part of the backlash against managed care might have actually glorified the importance of specialists—if health plans are trying to prevent this, it must be a good thing! Specialists’ incomes have since grown more rapidly than those of primary care physicians.⁷

Changes in bargaining leverage. One of the most visible trends in the era of loosening managed care was hospitals’ regaining leverage to negotiate rates with health plans. Many developments contributed. The earliest was the broadening of provider networks. After the managed care backlash, consumers expected that all of the prominent hospitals in the community, including academic medical centers, would be included in the network. More gradually, hospital mergers and acquisitions had an impact on leverage in the marketplace. Later, tight hospital capacity also contributed. Tight capacity resulted from a combination of the earlier reduction of capacity in response to declining use in the mid-1990s and rapid growth in use beginning in 2000, probably in response to the drop in authorization requirements. The distinct trends in hospital prices negotiated with private payers and use are described in HSC’s annual analysis of health care cost trends relevant to private insurance.⁸

Most physicians did not experience a comparable increase in leverage with health plans. This probably reflected the fact that no single medical practice has the market leverage that many individual hospitals have, so the practice’s absence from a network does less damage to consumers’ assessment of the network. The exception to this is that in some areas a single-specialty group might have a large enough share of the market that plans must negotiate a higher rate with that group. Very large multispecialty groups might have similar leverage. Whereas hospitals and physicians had price trends in 1995 of 3.7 percent and 3.1 percent, respectively, the 2004 price trends were 7 percent and 2.2 percent.⁹

Insurers’ market share. While insurers were loosening managed care in response to signals from their customers and changes in public policy, concentration in insurance markets was increasing. Toward the end of the 1990s, reflecting a turning of the underwriting cycle, insurers began to exit those markets in which they were unable to earn a profit. This included many situations in which national insurers had entered markets dominated by BCBS plans. Indeed, the relative position of the Blues strengthened with the loosening of managed care because of the diminishing importance of HMOs, which were generally a weak point for the Blues. Blue plans’ ability to negotiate lower rates with providers on the basis of their large market share became more important.

Cross-market mergers among insurers became more important. Many Blue plans merged, sometimes in conjunction with conversion to for-profit status. Commercial insurers merged with each other. Aetna acquired New York Life and Prudential.

Although most competition among insurers takes place at the local level, with market share being particularly important, many insurers perceived advantages of national scale. One factor was that large employers with many locations changed their strategy from constructing choices of plans in each market to contracting with a single insurer to provide a single option for each plan type at all locations. The Blues made themselves more attractive to employers seeking national contracts through creation of the Blue Card, which permitted a national employer to benefit from the strong provider networks that various local Blue plans had. Since no commercial insurer is strong in all markets, merging with others increased the number of markets of strength. Indeed, in addition to mergers among national commercial plans, national plans acquired strong local or regional plans in areas in which they did not have much market share. More recently, national insurers have negotiated arrangements with strong regional plans that give the plans access to each other’s provider networks.

Other factors behind cross-market mergers included scale economies in areas such as information technology (IT) and marketing. Although it does not get much notice, a major motivation in some mergers is the perception that the target company is poorly run and that better management can produce higher returns.

All of these changes in the insurance market were related in some way to the underwriting cycle. HSC began its observation of health care markets (in 1995) during the "hard" phase of the cycle, in which insurers sacrifice profitability to gain market share. But very poor financial returns in the latter part of the middle of the decade led to a reversal of the trend. Indeed, the phase in which premium trends exceeded cost trends has been a lengthy one, giving rise to discussions about whether the underwriting cycle has disappeared. Joy Grossman and I have argued that the cycle is likely to continue but have smaller amplitude, the result of increased ability to recognize changes in cost trends more quickly and increased barriers to entry because of managed care and market concentration.¹⁰

Recent Market Dynamics

Top Competition In 1995 Backlash Against Managed Care Markets Under Looser Managed... Recent Market Dynamics Potential Market Developments NOTES

 
Whereas much of the story outlined to this point reflects the growth and then loosening of managed care, the past two to three years have witnessed a new direction: greater dependence on the consumer to shape the direction of the delivery system. In contrast to the vision in the early 1990s that was built around IDSs and provider financial incentives, the current vision comprises patient financial incentives and tools to support consumers in choosing among providers and among different options for diagnosis and treatment.

Employers have again become vociferous about rising premiums, but instead of returning to more restrictive models of managed care, they have focused on revising the benefit structures of their plans to increase patient cost sharing. Although some of this reflects a shift in financial responsibility to employees, an important part reflects a change in incentives related to the use of services and choice of providers. From 2002 through 2004, changes in the benefit structure reflected a "buy-down" of about 3 percent per year, although the magnitude was notably smaller in 2005. The sharpest changes in cost sharing have been for prescription drugs, the category of services most sensitive to price.

Many have watched closely the development of consumer-driven health plans, which I define as plans with substantial patient financial incentives and an individual account that can be drawn from to pay medical expenses. Both regulatory decisions on the tax treatment of these plans and legislation that established health savings accounts (HSAs) have been important to the growth of these products. But to date, the changes in the benefit structure of HMOs and PPOs have probably had a more profound effect on the health system, if only because of the much larger numbers of insured people involved.

We are seeing selective reintroduction of administrative controls by health plans.¹¹ Not having forgotten the backlash against managed care, insurers have selected measures that were most effective and are least likely to anger physicians. Most prominent have been restrictions on imaging services, which have included a mix of authorization requirements and limitations on which facilities are eligible for payment.

Many observers have become concerned about the increasing degree of consolidation in both provider and insurer markets and what it implies for the potential for competitive approaches to constrain costs and improve the quality of care.¹² On the other hand, entrenched hospitals are increasingly facing competitive threats from new entrants: physician ventures.

Potential Market Developments

Top Competition In 1995 Backlash Against Managed Care Markets Under Looser Managed... Recent Market Dynamics Potential Market Developments NOTES

 
How might competition in health care evolve during the next few years? I expect that financial incentives for patients will continue to become more important, but refinements to the benefit structures that include substantial patient cost sharing will get more attention. More emphasis will be given to incentives to choose more efficient providers, although this will be constrained by slow development of reliable information. Another direction for refinement will involve reducing cost sharing for standard treatment regimens for chronic disease and increasing cost sharing for procedures that are more elective. The latter will not be easy, since it will involve going beyond some obvious treatments regarded as "lifestyle."

Consumer-driven care. The key challenge for consumer-driven care will be to influence the large percentage of health spending that is for patients who exceed even relatively large deductibles. For example, incentives to choose efficient providers could influence a much higher proportion of spending than a large deductible. If benefit structures are not refined from their current structure, in a few years we could reach the point at which acceptable amounts of patient cost sharing will have realized all of their potential to reduce the trend in health care spending, and other approaches will have to be pursued.

Choice of providers. Although much of the rhetoric of consumer-driven health care emphasizes patients’ active involvement in the details of their care, many consumers might still prefer the traditionally high degree of delegation of these details to a chosen provider. Competitive models might be built around consumers’ choices. What could differ from present is the degree to which consumers have valuable data on efficiency and quality of care with which to compare providers and financial incentives to motivate careful choices. Gains in quality and in cost control will then come from providers’ efforts to achieve these results spurred by competitive pressures on them. The key to this approach is useful information on quality and efficiency, which will have to surmount both technical obstacles and providers’ resistance to being judged on the basis of information that has limitations. Insurers have the potential to play a valuable role in structuring these provider choices.

Information technology and competition. IT, which appears to be finally going beyond experimentation, might have a number of implications for competition in health care. It is likely to be relevant to the scale of both hospitals and physicians’ practices. IT could favor large organizations because of their ability to use it more efficiently. This might force physicians in small practices to join larger ones. On the other hand, if an IT vendor could serve small practices efficiently on a subscription basis, the viability of those practices could be maintained.

Hospital consolidation. Hospitals are likely to continue to consolidate, motivated in part by access to capital. Many in the health care finance field have commented on the striking differences among hospitals in access. The implication is that those with poor access to capital might have to choose between withering away and losing market share to systems that have good access or finding a way to consolidate with them. This could provide an opportunity for for-profit systems to either acquire hospitals or to develop joint ventures with nonprofit hospitals.

Hospitals will probably retain their leverage with health plans but could use it more cautiously. If the FTC is successful in its pending challenges to implemented mergers, this could lead recently merged hospitals to be more cautious in exercising pricing power. Other hospitals will find that their margins have been restored to rates that they deem adequate and not use all of their leverage with health plans. Indeed, the entire notion of hospital cost shifting depends on nonprofit hospitals’ not always maximizing their net revenues.¹³

Medicare’s future impact. The Medicare program is likely to have more widespread impact on the health system than it has had historically. Of course, it will account for a rapidly growing proportion of the health system as the baby-boom generation becomes enrolled, but the beginning of that is six years away. But Medicare will also influence Medicaid plans and private insurers in areas such as provider reimbursement, quality measurement, and performance measurement. Medicare brings two important things to these areas. One is the ability to invest in research and development, especially through large-scale demonstrations. The other is credibility with providers, whose constituency organizations likely will have a "seat at the table" in developing tools to measure quality or efficiency.

Future role of competition. Whether competition will be an important part of the U.S. health system in the future remains an open question. A positive factor is the degree to which competition is now embraced by much of the political leadership, at least for other sectors of the economy. A negative factor is the degree to which many health care markets are already highly consolidated. One needs to think in terms of potential changes on the horizon that might disrupt these consolidated markets. Even more uncertain is the reaction of the public to changes in the way they obtain care. The public is likely to be less accepting of changes in how they get medical care than in how they purchase airline services. They will have to be shown that these changes are benefiting them with lower costs or higher quality. Public policymakers take great risks if competition is their only strategy to address cost and quality problems in health care.

Editor's Notes

 
Paul Ginsburg (pginsburg{at}hschange.org) is president of the Center for Studying Health System Change, in Washington, D.C.

An earlier version of this paper was presented at "Health Care Market Competition: How Well Can It Work?" at Lansdowne, Virginia, 29 April 2005. The meeting was cosponsored by Health Affairs, the Kaiser Permanente Institute for Health Policy, and the Center for Studying Health System Change. This paper was supported by the Kaiser Permanente Institute for Health Policy and the Robert Wood Johnson Foundation.

NOTES

Top Competition In 1995 Backlash Against Managed Care Markets Under Looser Managed... Recent Market Dynamics Potential Market Developments NOTES

 

1. See C.S. Lesser, P.B. Ginsburg, and K.J. Devers, "The End of an Era: What Became of the ‘Managed Care Revolution’ in 2001?" Health Services Research 38, no. 1, Part 2 (2003): 337–355.[CrossRef][Web of Science][Medline]
2. Henry J. Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits: 2004 Annual Survey, September 2004, www.kff.org/insurance/7148/index.cfm (23 September 2005).
3. Author’s calculations from Bureau of Labor Statistics series on the Producer Price Index.
4. Medicare Payment Assessment Commission, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2001), 180.
5. P.B. Ginsburg and C.S. Lesser, "The View from Communities," Journal of Health Politics, Policy and Law 24, no. 5 (1999): 1005–1013.[Medline]
6. C.S. Lesser, P.B. Ginsburg, and L.E. Felland, "Initial Findings from HSC’s 2005 Site Visits: Stage Set for Growing Health Care Cost and Access Problems," Issue Brief no. 97 (Washington: Center for Studying Health System Change, August 2005).
7. M.C. Reed and P.B. Ginsburg, "Behind the Times: Physician Income, 1995–99," Data Bulletin no. 24 (Washington: HSC, March 2003).
8. B.C. Strunk, P.B. Ginsburg, and J.P. Cookson, "Tracking Health Care Costs: Declining Growth Trend Pauses in 2004," Health Affairs, 21 June 2005, content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.286 (16 August 2005).
9. Ibid. Physician price trends were not reported in the above paper but were calculated using the same methods as for hospital trends.
10. J.M. Grossman and P.B. Ginsburg, "As the Health Insurance Underwriting Cycle Turns: What Next?" Health Affairs 23, no. 6 (2004): 91–102.[Abstract/Free Full Text]
11. G.P. Mays, G. Claxton, and J. White, "Managed Care Rebound? Recent Changes in Health Plans’ Cost Containment Strategies," Health Affairs, 11 August 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.427 (16 August 2005).
12. L.M. Nichols et al., "Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence Is Waning," Health Affairs 23, no. 2 (2004): 8–21.[Abstract/Free Full Text]
13. P.B. Ginsburg, "Can Hospitals and Physicians Shift the Effects of Cuts in Medicare Reimbursement to Private Payers?" Health Affairs, 8 October 2003, content.healthaffairs.org/cgi/content/abstract/hlthaff.w3.472 (16 August 2005).

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