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Healthcare Reform Calls for Enormous Payment Restructure for Health Care Providers and Facilities Healthcare reform has been a topic of great interest and a highly debated public issue for the past several years. Opinions are split on the reasons behind growing health care costs and methods to bring healthcare spending back in line. However, a consensus has formed surrounding the conviction that drastic changes must be implemented within our healthcare system.

Some of these changes include a complete restructure of the payment system for health care providers, health care facilities and insurance companies in effort to control the rising costs of health care within the United States. The rising costs of health care within the United States have long been a concern among economists. According to the Organisation for Economic Cooperation and Development (OECD), a forum in which the economic data of multiple countries is analyzed and compared, total United States spending on health care between 2000 and 2009 increased an average of 4. % per year. While this growth rate has been reduced to 2. 7% between 2009 and 2010, health care spending in the United States still equates to 17. 6% of the gross national product (GDP). This is significantly higher than the OECD 2010 health care percent of GDP average of 9. 5% (OECD Health Data 2012). These statistics demonstrate that health-related spending compared to other industrial countries and within the United States in outpacing spending on other goods and services. Rising health care costs are making health care less affordable for individuals, families, and businesses.

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These higher costs have a significant effect on government budgets at both the federal and state levels as well. Victor Fuchs, an emeritus professor of economics and health research and policy at Stanford University asserts, “approximately 50 percent of all the health care spending is now government spending. At the state and local level it is crowding out education, crowding out maintenance and repair of bridges and roads. At the federal level we have a huge deficit financed by borrowing from abroad. We are financing a huge deficit in Medicare and Medicaid by selling bonds, mostly to China. (Kolata) In terms of actual dollars, the United States health spending has nearly doubled in the past ten years. Rising from a reported $1. 3 trillion dollars in 1999 to $2. 5 trillion dollars in 2009, growing $96 billion dollars from 2008 to 2009 alone (Auerbach, and Kellermann 1630-1636). The United States cannot sustain the continued growth rate of health spending. “In 2007, the nonpartisan Congressional Budget Office projected that if health care spending in the United States stays on its current course, it will constitute half of the nation’s GDP by 2082” (Health Affairs, Auerbach & Kellermann).

Fortunately small changes in the annual per capital growth rates can produce considerable long-term effects. By reducing annual growth in per capita spending 1. 1%, a cumulative savings of $1. 42 trillion is projected for Medicare (Fisher, Bynum, and Skinner 849-855). Similarly, the United States health per capita, which is calculated by dividing the total health care expenditures by the total insured population, totaled $8,233 USD in 2010.

This means the US health per capita is $4,965 USD higher than the OECD average of $3,268 USD or roughly two-and-a-half times more (OECD Health Data 2012). The graphs below show the trending on both US health per capita and health as a percentage of the GDP for the past thirty years compared to similar industrialized countries. In 1980, the United States appeared to be in line with comparative nations but in the subsequent years we have deviated from the group and are clearly surpassing our peers in health care expense.

If the United States was once in line with comparative industrial nations what variables have led to the extreme gaps that can be seen today? What are the possible explanations for the excessive US costs? Pinpointing the exact causes for higher costs within the United States health care systems is challenging. Several factors are likely to impact the costs of health care across the United States. The most often stated reason is the aging of the US population. “The percentage of the American population age 65 or over is 12. now and is projected to rise to about 21 by 2050. ” (Reinhardt, Health Care Costs Part V). It is generally accepted that as individuals age they require additional health services due to new complications or chronic conditions. While this may be true, an aging population cannot be the only rationale for higher spending. “In a number of other industrialized countries — notably in Japan, Germany, Italy and Sweden — the elderly already represent close to 20 percent of the population, a level the United States will not reach ntil about 2040”(Reinhardt, Health Care Costs Part V). The disparity in US health care spending consequently cannot be the rationale if the countries of Japan and Italy, whose health expenditure as a percent of the GDP and health per capita are below the OECD average, are comprised of a greater amount of elderly consumers the United States. Further research has shown that the aging of a population alone added only an approximate half percentage point to the per capita health spending annual rate in industrial societies (Reinhardt, Health Care Costs Part III).

Another potential reason for higher health care spending in the United States is greater access to medical advances in both technology and pharmaceuticals. The availability and accessibility of computed tomographic (CT) scans and magnetic resonance imaging (MRI) imaging across industrial nations is measured by the OECD. “There were 40. 7 CT scanners per million population in 2011, a number that is almost double the OECD average of 22. 6. And there were 31. 6 MRIs per million population, two-and-a-half times the OECD average of 12. 5” (OECD).

The availability alone, however, does not seem to be a driver of increased health care costs. Regional variations of health spending within the United States show an increase of technology utilization in higher spending regions due mainly to medical discretionary of physicians. The research of Drs. Sutherland, Fisher, and Skinner show patients in the highest spending regions “undergo more magnetic resonance imaging (MRI) procedures (21. 9 vs. 16. 6 per 100 beneficiaries) and computed tomographic (CT) scans (61. 4 vs. 46. 9 per 100 beneficiaries). To this end, controlling cost will require physicians’ assistance in eliminating excessive procedures and their leadership to help educate the public as to the appropriate usage of such procedures. “If the entire country were brought to the spending level of the lowest quintile, the savings would be about $750 per capita: $225 billion or 21% of the gap” (Hixen, Forbes) The United States also exhibits higher costs for medications. “The United States tends to be an early adopter of newly launched drugs, which are patent protected and sold at higher prices” (McKinsey & Company).

The increased availability of these new drugs hastens the wide spread usage and these higher priced prescriptions quickly become some of the most preferred medications among US consumers. Whereas the lack of availability in comparative nations maintains lower prescription drug costs by the increased utilization of generic medications as a substitute to new formulas. To support the conclusions that medication is truly a higher cost within the United States, McKinsey Global institute compared usage of medications in addition to cost.

According to their findings, usage of prescription drugs is approximately 20 percent lower in US patients than in other nations. Therefore, medications are priced higher in the United States and thus contribute to the higher spending in the United States (McKinsey & Company). Physician and Specialist costs have also been identified as potential factors in the elevated costs of United States health care spending. The McKinsey analysis of OECD comparative countries shows, “physician compensation is, on average, 4 times GDP per capita for specialist and 3. 2 times for generalists.

In the United States, these figures rise to 6. 6 and 4. 2 respectively. ” Therefore, it should come as no surprise that on a per capita basis annual spending within the United States is approximately five times higher than peer countries, reported at $1,600 versus $310 per capita, or a difference of $1,290 per capita, which equates to $390 billion dollars nationally (Hixen, Forbes). The United States also has a disproportionate amount of specialist compared to other countries. In the majority of industrial countries the ratio of specialists to primary care physicians is one-to-one.

The United States currently contains a two-to-one ratio of specialists to primary care physicians. The effect to spending is compounded since US specialists get paid more per hour and their spending is typically already higher due to more exotic interventions (Kolata). “Although payments to primary care physicians were greater in the United States than elsewhere, the differential was smaller than would be expected given the costliness of the overall US health care system”(Laugesen, and Glied 1647-1656).

Therefore it is more likely that higher physician compensation is not due to higher education costs or greater skill levels, instead physicians are paid more per service in the United States than in comparative industrial countries. Overall, higher prices can be linked to higher US health spending. Public and private payers paid higher fees (27 percent more for public and 70 percent more for private) to US primary care physicians for office visits and much higher fees to specialists than comparable fees paid to physicians in other industrial countries (Laugesen, and Glied 1647-1656).

A final potential contributor to the higher health expenditures are the higher administrative costs of the unique United States health care system. “The United States spent $412 per capita on health care administration and insurance in 2003 –nearly six times as much as the OECD average” (McKinsey & Company). The combination of the various private and public health options and numerous regulations across the nation increase the complexities of administering healthcare thus raising the costs to do so. (McKinsey & Company).

The reduction of administrative costs will be a challenge in the current state of the United States health care system however; the opportunity exists and can be addressed during health care reform initiatives. With so many potential reasons it is clear that no single factor is either a cause or magic solution for reform initiatives. Some would argue that perhaps the rising cost of health care within the United States is justified by higher quality and efficiency in the system. Unfortunately this is not the case.

A recently released report from the Commonwealth Fund compares the health systems of six other industrialized countries across five areas: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives. The United States ranked a dismal last in overall performance compared to the other six industrialized countries suggesting that not only are the costs of health care out of line in the United States but the services provided at these higher costs are of a lower value (“Eurek Alert”).

The table below highlights the findings of the Commonwealth study. In the area of quality the United States received their highest ranking of 4th in the specific categories of effective care and patient-centric care. In the remaining categories of safety, coordinated care, access, efficiency, equity, and life quality the United States was within the bottom three if not the last. US patients with chronic conditions reported a higher rate of receiving an incorrect dose of medication decreasing the safety rankings.

Delays in obtaining abnormal test results and 13% higher level of reported avoidable emergency room visits contributed to the poor ratings of coordinated care and efficiency. US patients also overwhelmingly reported difficulty affording the health care they need. Many patients became non-compliant with medication or follow-up care or avoided necessary care altogether due to costs. The 7th place ranking of the United States of healthy lives is associated with the high rate of infant mortalities and potentially preventable deaths before the age of 75 (“Eurek Alert”).

The United States, as an industrial nation, should have higher increases in life expectancy to match the rate of health care spending. The graph to the right compares total expenditure on health per capita in USD to the average life expectancy at birth. The US life expectancy in 2010 was 78. 7 years, which is one full year below the OECD average life expectancy of 79. 8 years. Other industrial nations, such as Japan, Italy and Spain, report at least half of the amount of US expenditures on health per capita and have life expectancies which exceed 82 years.

This is not to say the life expectancy at birth has not been increasing in the US. In fact the OECD reports “In the United States, life expectancy at birth increased by almost 9 years between 1960 and 2010, but this is less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. ” Upon review of these figures, the necessity for controlling the rising costs of health care in the United States becomes abundantly clear. Health care reform is a necessity. Reformers have suggested a complete reversal in the structure and approach to the delivery of health care within the United States.

The current method of reactive individual care will need to be displaced by the “triple aim,” a three tiered simultaneous goal of health care reform to lower costs, improve care and promote better health across the population. Improving the quality while simultaneously lowering the costs of the complex health care system of the United States will require a multi-level approach. “The alternative approach to controlling costs is to support a healthcare system in which individual decisions of both the provider and patient are much better aligned with value” (McClellan 69-92).

The objectives to reduce per capita costs of health care, improve the general health of the population, and expand the experience of patient care seem intuitive yet at the same time challenging to achieve. Triple aim components are not independent of one another, instead they are tenuously linked. An adjustment to one component can have either a positive or negative effect on the other components. Reducing the use of specialists, expensive testing, and new medication usage can improve the goals of cost reduction and general health, but might produce a long-term negative effect on the individual experience by limiting technological advances. A health system capable of continual improvement on all three aims, under whatever constraints policy creates, looks quite different from one designed for the first aim only. The balanced pursuit of the Triple Aim is not congruent with the current business models of any but a tiny number of U. S. health care organizations” (Berwick, Nolan, and Whittington 759-769). A key feature of this new philosophy is the focus on the complete health of a subgroup or “population. ” Population management anticipates and shape patterns of care rather than reacting to the acute needs at the individual patient level. Only when the population is specified does it become, in principle, possible to know about its experiences of care, its health status, and the per capita costs of caring for it”(Berwick, Nolan, and Whittington 759-769). Capturing and tracking this population data overtime to assist physicians with proactive and preventative treatment plans will require research, development and investment. It is important to note a population cannot exclude individual members or subgroups. To achieve the triple aim, all citizen must have access to the same level of service.

Another fundamental element in achieving the triple aim is the integrator. An integrator is an entity, whether it consists of a hospital with an affiliated physician group, a large primary care group, or a creative insurer, that accepts responsibility for all three components for a specific population (Berwick, Nolan, and Whittington 759-769). An effective integrator will bridge the gaps of the multi-faceted health care system and coordinate behavior among health service suppliers to work as a system for the defined population.

To achieve these goals the integrator will need to be a single organization with the mission “to change the ‘more-is-better’ culture through transparency, systematic education, communication, and shared decision making with patients and communities, rather than by restricting access, shifting costs, or erecting administrative hurdles to care” (Berwick, Nolan, and Whittington 759-769). Health care will be challenged to expand beyond the four walls of the health care facility and deliver creative and comprehensive care to patients in their daily lives. Many members of the population, especially those with chronic illnesses, will need someone who can work with them to establish a plan for their ongoing care, guide them through the technological jungle of acute care, advocate for them, and interpret” (Berwick, Nolan, and Whittington 759-769). New methods to provide service are emerging as technology advances. Health care providers are beginning to use e-mail, telephone, teleconference and virtual media to deliver services and potentially reduce the high rates of specialist referrals or visits.

However, this expanded level of care requires a greater time commitment on the part of the primary care physician and his or her care team- time which is currently not incentivized or reimbursed. “Eliminating unnecessary care therefore requires reorganizing the delivery system to ensure that providers aren’t penalized for providing what is often the better alternative for their patients” (Sutherland, Fisher, and Jonathan 1227-1230). “The broken financing system of the present mirrors the fragmented care system” (Berwick, Nolan, and Whittington 759-769).

Current payment to United States health care facilities and providers are based on a system which encourages utilization of health care services regardless of necessity. Since 1996, the United States health system has operated under a fee-for-service payment method. Under this payment structure, a provider or facility typically receives a set fee for a particular service, such as a routine physician office visit or an inpatient stay at a hospital. These fees are characteristically paid through a combination of patient and insurer, either public or private.

Each year these set fees are reviewed and adjusted according to volumes of service types. Typically there is minimal reduction in fees, despite advances in efficiency by means of technology, because the review board is partially comprised of physicians. Many analysts believe this value scale is highly distorted and no longer reflects relative costs (Ginsburg 1977-1983). Hence, fee-for-service drives the volume based productivity of United States physicians, specialists and health care facilities. The Fee-for-service format creates incentives to see more patients than other formats would – especially since subjective clinical judgment guides treatment intervals and consultations in most cases. Not surprisingly, then, do physicians in the United States see, on average, 1. 6 times more patients than do physicians in other countries” (McKinsey & Company). The fee-for service model of payment has two additional drawbacks. With the objective to service as many patients as possible in the shortest amount of time frame physicians are not encouraged to educate patients on the importance of preventative measures and unnecessary procedures. Hospitals lose money when they improve care in ways that reduce admissions, and they lose market share when they don’t keep pace in the local medical arms race. In this race there are no financial rewards for collaboration, coordination, or conservative practice. ” (Fisher, Bynum ; Skinner). The co-ownership of many outpatient facilities such as ambulatory surgery centers (ASC), diagnostic imaging centers (DIC), and diagnostic testing and procedure laboratories by United States physicians also impedes the success of the fee-for-service payment model in cost containment.

With ownership, physicians receive additional profits for consultations and procedures referred to these facilities. These alignments directly conflicts with the need to reduce unnecessary services (McKinsey ; Company). To achieve the triple aim, new payment methods will have to be devised. The concern is that continued dependence on fee-for-service payments, which reward high utilization and promotes variable expense for different subpopulations, threatens the necessary practice transformation and the expressed goals of delivery system reform.

The practices that are rewarded are the practices that are implemented. To create the desired behavioral changes new financing and competitive dynamics are required (Berwick, Nolan, and Whittington 759-769). “Transitioning from a fee-for-service payment system, with its emphasis on volume, to a more value-driven payment model that encourages better health care at lower cost will require realignment of financial incentives” (Goroll, and Schoenbaum 577-578). The economic objective of provider payment reforms is to give healthcare providers as a group an incentive to offer the right care for each patient—care that is well-coordinated and efficient for each individual, which means both giving difficult cases the extra resources required while conserving resources when they would not be well-used” (McClellan 69-92). Payment reform needs to be staged-in and coordinated with the implementation of practice reform, permitting time for the required changes to occur in practice culture, care delivery, and information systems.

Over the course of recent health care reform initiatives, several new methods are quickly being devised, tested and realized (Goroll, and Schoenbaum 577-578). Following in the footsteps of peer industrial nations, the United States has begun to explore supplementary methods of health service payment by incorporating elements of quality-related bonuses, incentive payment, bundling similar services, and shared savings programs thereby fostering culpability for overall costs and quality of care. “Pay for Reporting” is one of these new payment methods.

In the pay for reporting model additional payments are tied to the ability to provide information related to quality of care measurements. The goal is to obtain long-term data on both health outcomes and associated costs. Presently Medicare offers pay for reporting to both hospitals and physicians who disclose a set of specialty specific quality measures related to the use of evidence-based processes of care. “Such payments have had a substantial effect: virtually all U. S. hospitals now participate in Medicare quality reporting, and as a result, more healthcare performance measures are becoming available” (McClellan 69-92).

There is also some evidence that providing information to the public inherently leads to quality improvements. Increased knowledge of meaningful data is essential to revising the United States health care system. “Consequently, incentives or requirements to report on quality are a prerequisite for all of the reforms that follow” (McClellan 69-92). A second reimbursement model that has recently been implemented in the United States health care system by a handful of insurance plans is the “pay for performance” model.

Payments in the pay for performance model are issued upon improvement of predetermined quality metrics. In 2003, Medicare instituted a hospital pay for performance program in which reimbursement is tied to performance within a set of 33 clinical measures, including the administration of aspirin to heart attack patients and assessing the oxygen levels of pneumonia patients. The program is linked to significant quality improvements and appears to reduce the costly complications associated with the chronic conditions.

However, overall cost savings are hard to detect. Some analyst report “trend comparisons with hospitals that reported on quality without a pay-for-performance program showed that most of this effect was associated with underlying time trends and not pay-for-performance per se” (McClellan 69-92). In the practice setting of the United States health care system pay for performance also occurs in the form of “medical homes. ” The objective is to better manage care for chronic diseases and prevent costly complications.

Physicians are financially rewarded for spending more time with high risk patients. Studies are split in their findings regarding the impact physician pay for performance methods have on the total quality and cost of patient care (McClellan 69-92). Health information technology is also widely incented by pay for performance methods through the 2009 economic stimulus program of “meaningful use. ” Along the lines of pay for reporting an increased knowledge of meaningful data is essential to revising the United States health care system. Meaningful use” combines the two methods by first rewarding the ability to report on quality measures through a shared information system with the ability to track the patient population and secondly providing addition payment for the achievement in attaining certain clinical criteria (McClellan 69-92). Concerted efforts are underway to combine payments across multiple providers and settings in a broader manner that will go beyond providing incentives for performance. Bundled payments provide a means in achieving this objective. Bundled Payments are not a new concept within the fee-for-service payment method.

Recently efforts have been taken to expand and include quality metrics within these bundled payments. “For example, in the case of diabetes, some quality measures might include how well-controlled a patient’s blood sugar was, the rate of hospitalization of patients with potentially preventable diabetic complications, and patients’ assessment of their overall experience with care” (McClellan 69-92). Historically such measurements have not been included in the traditional, provider or facility specific episode-based bundled payments.

The enlargement and broadening of “bundles” for payment across multiple providers is extremely challenging due to the constant evolving of health knowledge and the growing crossover between chronic disease complications. Nevertheless, the opportunities for improving quality while lowering costs could be substantial. “Whether these reductions in intensity and costs within the bundles resulted in lower overall spending growth is less clear, but their impact on costs within the ‘silo’ of bundled care and their potential for lowering overall costs is unquestionably a key reason for their more widespread use”(McClellan 69-92).

The most drastic proposed change to the current payment system in United States health care is through capitated payments and shared savings. The intricacies of outlining specific bundles of care for various chronic conditions can be avoided by bundling payment for all health care services together. A launching point for this proposal stems from health maintenance organizations (HMO) and preferred provider organizations (PPO) in which an insurance plan organizes a large network of services and regulates the usage and cost with capitated payments.

The members within the insurance plan therefore become the population requiring managed and coordinated care for which fixed payments are provided on a service level basis. In some instances the providers share the financial risk for overall patient costs, not just the services provided, and split the cost savings with the HMO or PPO. “In recent years, Medicare has similarly tried out reforms that enable providers to ‘share savings’ that are achieved in overall per-capita spending. These developments are leading to what has come to be called “accountable care organizations” (McClellan 69-92).

An accountable care organization (ACO) is comprised of a network of health care providers that share responsibility and are held accountable for the overall costs and quality for an identifiable population of at minimum 5000 Medicare patients. “The ACO would bring together the different component parts of care for the patient – primary care, specialist, hospitals, home health care, etc. – and ensure that all of the ‘parts work well together”’(Gold). Under an ACO patients would have access with coordination to an entire health care package.

Within the current United States health care system, patients shop around for care which is disjointed by the lack of communication between providers. Unlike HMOs patients would not be limited to services within the ACO, instead it would be the responsibility of the ACO to coordinate with any resources utilized outside of the network (Gold). The Medicare ACO Shared Savings Program launched in April of 2012 with regulations for participation within the program surround the core concepts to achieve better care for individuals, better health for populations and lower expenditures for Medicare, in other words the Triple Aim.

Two payment options are available for shared savings. ACOs can either assume a smaller share of upside gain with no risk of loss for the first two years of operation, transitioning to full risk in the third year, or ACOs can incur full responsibility for patient service cost at inception thereby receiving a higher percentage of shared savings or risk (Berwick 1-4). “Provider payment reform is a work in progress. As the capacity to measure health are processes and outcomes continues to expand rapidly, in conjunction with at least some growing confidence that we are measuring the right things, the linkages between provider payments and measured quality are likely to strengthen” (McClellan 69-92). Most likely a combination of the aforementioned payment reform methods will surface as the structure and focus of the United States health care systems shifts towards the triple aim goals. Integrated health care delivery systems that are responsible for populations cannot flourish unless payment systems encourage their development and laws and regulations support their growth.

A joint effort will be required on the part of physicians, specialists, insurance companies, employers, government and the individual patient to influence any effective reform initiatives. If all the stakeholders can agree on the triple aim vision of a United States health care system, the development of professionally led, integrated systems can be achieved. Work Cited “Accounting for the Cost of Health Care in the United States. ” McKinsey Global Institute. McKinsey ; Company, Jan 2007. Web. 11 Sep 2012.

Auerbach, David, and Arthur Kellermann. “A Decade Of Health Care Cost Growth Has Wiped Out Real Income Gains For An Average US Family. ” Health Affairs. 30. 9 (2011): 1630-1636. Print. Berwick, Donald. “Launching Accountable Care Organizations – The Proposed Rule for Medicare Shared Savings Programs. ” New England Journal of Medicine. 10. 1056 (2011): 1-4. Web. 5 Sep. 2012. Berwick, Donald, Thomas Nolan, and John Whittington. “The Triple Aim: Care, Health, And Cost. ” Health Affairs. 27. 3 (2008): 759-769. Print.

Fisher, Elliott, Julie Bynum, and Jonathan Skinner. “Slowing the Growth of Health Care Costs – Lessons from Regional Variation. ” New England Journal of Medicine. 360. 9 (2009): 849-855. Print. Ginsburg, Paul. “Fee-For-Service Will Remain A Feature Of Major Payment Reforms, Requiring More Changes In Medicare Physician Payment. ” Health Affairs. 31. 9 (2012): 1977-1983. Print. Gold, Jenny. “ACO is the hottest three-letter word in health care. ” Kaiser Health News. Kaiser Family Foundation, 21 Oct 2011. Web. 1 Sep 2012.

Goroll, Allan, and Stephen Schoenbaum. “Payment Reform for Primary Care Within the Accountable Care Organization. ” Journal American Medical Association. 308. 6 (2012): 577-578. Web. 2 Sep. 2012. Kolata, Gina. “Knotty Challenges in Health Care Costs. ” New York Times 05 Mar 2012, Web. 11 Sep. 2012. Laugesen, Miriam, and Sherry Glied. “Higher Fees Paid to US Physicians Drive Higher Spending For Physician Services Compared to Other Countries. ” Health Affairs. 30. 9 (2011): 1647-1656. Print. McClellan, Mark. Reforming Payments to Healthcare Providers: The Key to Slowing Healthcare Cost Growth While Improving Quality?. ” Journal of Economic Prespectives. 25. 2 (Spring 2011): 69-92. Print. “OECD Health Data 2012. ” How Does the United States Compare. Organization for Economic Cooperation and Development, June 2012. Web. 1 Sep 2012. Reinhardt, Uwe. “Why does U. S. Health Care Cost so Much? (Part III: An Aging Population Isn’t the Reason). ” Economix: Explaining the Science of Everyday Life. The New York Times, 05 Dec 2008. Web. Web. 2 Sep. 2012.

Reinhardt, Uwe. “Why does U. S. Health Care Cost so Much? (Part V: Can Americans Afford Medicare? ). ” Economix: Explaining the Science of Everyday Life. The New York Times, 05 Dec 2008. Web. 2 Sep. 2012. Sutherland, Jason, Elliott Fisher, and Skinner Jonathan. “Getting Past Denial – The High Cost of Health Care in the United States. ” New England Journal of Medicine. 361. 13 (2009): 1227-1230. Print. “US Ranks Last among 7 countries on health system performance. ” Eurek Alert Organization. Commonwealth Fund, 23 June 2010. Web. 1 Sep 2012.

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