Purchasers and the impact of managed care on physicians. (Value-Based Health Care).

PHYSICIANS IN PRACTICE ARE INTENSELY AWARE THAT managed care represents a change in the way that medicine is practiced. Which patients physicians see, whether care is authorized, and how professional services are compensated are activities fundamental to modern medical practice, which is undergoing radical transformation along lines shaped by managed care organizations (MCOs). Based on this direct experience many physicians believe that the changes in American health care impacting their professional lives have been caused by MCOs. These physicians seek to understand the new health care environment and to limit its impact by controlling the way MCOs operate. (1)

These physicians are mistaken in their belief that MCOs are the fundamental force changing the U.S. health care system: MCOs are only messengers. This error also serves to blind physicians to the greater marketplace dynamics--the real forces shaping U.S. health care. It can create an "us versus them" mentality in which progress or understanding is difficult. Finally, it leaves physicians on the sidelines at a time when their voices are critical to defining the emerging health care system in a way that can satisfy the needs of patients, physicians, and purchasers alike.

It is not a new phenomenon that the economics of health care are shaping the practice of medicine. The rise of the Blue Cross and Blue Shield programs during the 1950s helped to create stable funding for physicians and hospitals. This, in turn, impacted medical practice and made becoming a physician much more desirable; before this, many physicians earned incomes below the poverty level. (2) It also introduced the "usual, customary, and reasonable" reimbursement methodology that came to define fee-for-service medicine and institutionalized the higher fees specialists could charge, making specialization more economically attractive.

The implementation of Diagnosis Related Groups ("DRGs") for hospital reimbursement is another example of how changes in the way that health care is purchased can drive profound changes in how medical services are delivered. The DRG payment methodology has resulted in shortened hospital stays, lower inpatient costs, the growth of home care and alternative service settings, and the introduction of case management, critical paths, and utilization management programs by hospitals. (3)

Similar forces are at work as purchasers drive changes in medical practice, with managed care organizations acting as intermediaries. Understanding this process means both grasping the pressures that managed care organizations face and the strategies that employers are using to address their cost and quality concerns. Physicians who understand these forces will not only be better prepared to deal with the demands of MCOs, but they will also be in a position to prepare for the developments already occurring, which may allow them to regain control of health care delivery by dealing directly with purchasers.

The relationship between purchasers and managed care organizations

Purchasers of health care include not only employers obtaining health care coverage for their employees, but also governmental purchasers through Medicare, Medicaid, CHAMPUS, Department of Defense, Federal Employees Health Benefit Programs, and other public programs. While there is a wide variation In the objectives and mechanisms by which these purchasers operate, they share common concerns over the cost and quality of the services they purchase, and have begun acting in concert to define health care standards.

In some areas, employers have also started to band together to purchase health care jointly in local purchasing coalitions. (4) This is placing increasing cost and quality pressures on MCOs. Other purchaser initiatives, such as the Health Plan and Employer Data and Information Set (HEDIS) and Foundation for Accountability (FACCT) are mandating standardized measures of health plan performance. (5)

MCOs are the immediate focus of these demands. Figure 1 outlines the relationships between purchasers, which include both private employers and state and federal programs; payers, like MCOs and traditional insurance carriers; and providers, including physicians, hospitals, pharmacies, laboratories, and other health care services. ft illustrates that purchaser demands are transmitted to a health care marketplace. Payers that can meet employer demands for price, quality, and service are rewarded with membership, revenue, and growth. Those insurers and MCOs that cannot compete will be acquired or eliminated.

Because there are many MCOs in competition and costs are relatively low for employers to switch from one to another, the marketplace is becoming highly competitive. The further concentration of power by purchasers through national coalitions and cooperative efforts with governmental purchasers means even more pressure on MCOs, resulting in consolidation, declining margins, and decreased profitability.

This intensive purchaser pressure is a relatively new development, and to understand its appearance and dramatic impact it is necessary to enter briefly into the world of the large corporation. In the past, employee benefits like health care were treated almost as an entitlement, as If a health plan were a right of employees, and the employer's role was simply to select a health plan and then pay the costs. With the rise in costs and the increasingly competitive nature of the U.S. business community, health benefits have been transformed from an entitlement into one of the employer's largest costs of production.

Companies that can purchase a health plan for less than their competitors can turn this into a competitive advantage, pricing their products lower, gaining market share, and improving their profitability. Companies that can offer their employees more attractive benefits will recruit and retain a better workforce and gain additional competitive advantage through enhanced productivity. Purchasing health care is becoming a strategic business activity and Is receiving the corporate attention appropriate to its high cost. While the public attempt to reform the health care system through political means in recent years has yielded modest results, corporate efforts have been proceeding dramatically. (6)

These corporate changes in purchasing are influenced by benefit managers who have increasing responsibility in developing employee programs, including health benefit design, employee contribution strategy, and coverage of retirees and dependents. Their goal to enhance quality and reduce costs has resulted in a dramatic evolution of these programs. As outlined in Table 1, benefits managers' efforts in the 1980s drove the change away from indemnity plans, such as Blue Cross/Blue Shield, which feature fee-for-service reimbursement.

In their place, early managed care plans came into national prominence, especially Preferred Provider Organizations (PPOs) and national Point of Service (POS) arrangements which featured some cost control elements. While these pioneering efforts, often modeled on the Allied Signal arrangement with CIGNA, met with some success, the limited choice of plans and lack of control over health care delivery prompted further changes.

In the early 1990s, managed competition models first arose, which featured competition between several indemnity, PPO, and HMO choices in each employee location. This approach, made prominent by companies including Xerox and GTE, required employees to pay some part of the premium proportional to the employer's cost. The employee chooses between health plans based on this direct expense and the perceived quality of the alternatives, generating real competition. (7)

This competition has driven the demand for better health plan performance measures, including: NCQA accreditation. Intended as a seal of approval, employer requirements have driven more than half of the HMOs in the country to seek accreditation by the National Committee for Quality Assurance. This process allows an employer to represent to Its employees that accredited MCOs meet basic standards for quality, and may help protect an employer from potential liability for torts committed by the plan or its providers, through due diligence in health plan selection. (8)

HEDIS The Healthplan Employer Data and Information Set, of which the current version 3.0 was released in the Fall of 1996, offers more than 60 explicit performance measures that standardize the tracking and reporting of quality, utilization, access, satisfaction, and financial performance

Information. The data has been audited by some purchasers and national auditing standards and approaches have recently been adopted by the NCQA. For many large employers, HEDIS data serves as the basis of health plan selection and performance guarantees. It also incorporates outcome measures, the next generation of performance assessment. (9)

Satisfaction surveys Purchasers are also directly assessing the perceived value of their health plan choices by conducting employee satisfaction surveys. These generally include measures relating to the overall plan, its providers, and its administrative services. Most recently, the National Committee on Quality Assurance has released a standardized survey, the Annual Member Health Survey, which will allow meaningful, statistically valid comparisons across health plans. This promises to become widely adopted by employers.(10) HCFA has also mandated the CARPS survey (Consumer Assessment of Health Plan Satisfaction) for all Medicare risk HMOs, and Intends to publish the results widely to assist its beneficiaries in their health plan selection.

Report Cards Perhaps the most recent development is the introduction of side-by-side comparisons of health plan performance which corporations prepare for their employees. This may include HEDIS measures and NCQA accreditation status, as well as information on board certification rates, choice of hospitals, and whether the MCO uses Centers of Excellence for transplantations. Figure 2 is a sample of one such report card which is distributed at the annual open enrollment and guides health coverage selection by the employee.

These measures, together with the costs of premiums, are the instruments by which health plans are being compared, selected, and eliminated in the marketplace.

Impact on physicians

Purchasers are demanding that payers offer lower costs and demonstrate superior results on these performance measures. MCOs and other payers that do not meet these demands risk elimination. The result can be an increasingly burdensome and intrusive presence by the MCO In the physician's practice, since it is ultimately the physician who determines both cost and health plan performance. If the MCO cannot impact the physician's practice to improve its overall costs and performance, it will not be able to meet purchaser demands.

Some of these impacts on physicians are direct and immediate. MCO utilization management, for example, has been particularly burdensome to physicians, and has been characterized as threatening professional autonomy, straining the physician-patient relationship, and sometimes threatening patients' health. Other efforts to control the cost of health care, including salaried arrangements, capitation, and ownership of physician practices have been equally troubling for physicians.

Economic profiling is another example, which describes a physician's practice pattern relative to his or her peers in terms of the utilization of services per member, and perhaps in actual dollars spent per member per month. MCOs use profiling results to change physicians' practice patterns. Consequently, physicians with high-cost practice patterns are restricted or eliminated from an MCO's panel of providers through economic credentialing. This prospect is alarming, but it is difficult to see how an MCO can control health care costs and respond to purchasers without holding physicians accountable for the cost and quality of their practice patterns. Purchaser pressures to lower health care costs will not allow the return of the unrestricted fee-for-service model, regardless of whether MCOs or economic credentialing survive in their present forms. (11)

Purchaser efforts to control costs are also driving other MCO-mediated changes in physician practice. Physicians are seeking the economies of scale and administrative efficiencies that come with organizing into larger groups. Solo practitioners are no longer the norm in the U.S., being replaced by single- and multi-specialty groups. Integrated delivery systems, also called physician-hospital organizations, organized systems of care, and provider service networks have appeared as a logical extension of this organizational trend and hold the promise of increasing physician control over health care delivery. These organizations not only offer the administrative sophistication to manage care efficiently, but they also are in a position to accept capitation for managing all of a member's care, effectively removing the MCO from the delivery of health care services.

But employer efforts to control cost are only part of the burden on MCOs and physicians. Equally important is the drive to improve quality, to enhance the results of the health plan measures that employers use to select and manage plans. As competition increases, cost differences between health plans get smaller, and employers make selections based on factors such as NCQA accreditation, how well health plans perform on the HEDIS measures, and member satisfaction with access, choice of physicians and hospitals, and overall services. These issues impact physicians as health plans struggle to improve their performance and their competitive market position.

Table 2 lists some of these performance measures and how they affect physicians with whom the plan contracts. NCQA accreditation, for example, requires that a health plan perform primary source verification of a physician's credentials, including medical school graduation, residency and specialty training, state licensure, and board certification status. Physicians must provide either the original documents proving these credentialing elements, or help the plan obtain alternative verification through direct access to medical school records, training hospitals, and state medical boards. Not only must this be done initially, but some of these elements must be confirmed as part of routine recredentialing every two years. It is easy to see how this obligation on physicians can lead to resentment and frustration. (12)

Perhaps one of the requirements most difficult for physicians to accept is providing patient encounter data. For physicians who bill health plans on a fee-for-service, discount, or schedule basis, MCOs can track most services to members. To determine mammography rates, for example, an MCO can simply look at a given physician's billing records. Summing this information across all its physicians will determine the MCO's overall mammography rate, an important HEDIS measure. But where services are capitated, the health plan requires each physician to capture this information from office systems and submit it in a verifiable format, often necessitating laborious efforts and new office management systems.

Clearly, these purchaser requirements which are mediated by MCOs impose an additional level of demand on a physician's practice. Another example are the visits by health plan personnel to examine member records. These activities are necessary for HEDIS measures like pediatric immunization, where the exact nature, timing, and administration of vaccinations cannot be determined from billing records alone. Office reviews of member records are also necessary to meet various health plan performance requirements for medical records (NCQA accreditation) and clinical encounter information (HEDIS).

What's next?

Purchasers' MCO-mediated demands on physicians will increase markedly in the next few years due to increasing sophistication on the part of those who pay for health care, and a growing concern that many of those health care dollars have been spent on unnecessary care in the past. (13) American corporations have been undergoing profound changes during the 1990s, with a lean-and-hungry drive to cut payrolls, enhance productivity, and increase competitiveness. These changes are now reaching the corporate staff that purchases health benefits, and the result will likely be that their demands as purchasers for higher quality, lower costs, and more effective health care will dwarf the changes that have occurred since the appearance of managed care.

These purchasers' demands can be understood through the concept of value-based purchasing, which is emerging as a common corporate strategy. Very simply, corporations seek to maximize the dollars they spend for health care so they can gain an advantage over their domestic and international competitors. If General Motors, for example, can reduce its health care costs and simultaneously increase the quality of the medical care its employees receive, it can sell more of its automobiles at a lower price and edge out Ford, Toyota, and Volkswagen in the marketplace.

The value equation

To gain this advantage, the corporation must be able to measure the impact of its health care spending, much as it would evaluate the effectiveness of buying various grades of steel or providing different pension plans. The value equation is a conceptual approach to this measurement:

Value = Worth/Cost

The cost is the health plan premium expense that a corporation pays for each of its employees, or the average cost per employee if the health plan is a self-funded indemnity or PPO plan. To measure the worth, corporations look at the positive impact of providing health care to their beneficiaries, which includes compensation, quality, and productivity

Compensation here means that employees receive a health plan instead of the equivalent in direct wages, and how much employees appreciate that plan and see it as an advantage of working for the employer is a direct measure of whether the dollars spent enhance morale and improve recruitment and retention. Quality in this context does not mean features like hospital JCAHO accreditation, but rather the health care outcomes that a given health plan produces. For example, if a plan has a lower mortality rate for common diseases, better preventive health services, and superior results for surgeries and medical procedures, then it is worth more than one that cannot produce these outcomes. And finally, some health plans are more effective at keeping employees healthy, productive, and at work, and this is worth more to an employer, who after all needs that employee at work to generate the revenue that pays for health care in the first place.

Armed with this understanding of what they want in the health care marketplace, purchasers are demanding that MCOs and physicians provide information to demonstrate how they perform on these value parameters.

"Accountability" is one label applied to this new approach, meaning that MCOs and their providers are expected not only to deliver medical services, but also to produce health results for the corporation's beneficiaries.

These results are measured by outcomes. HEDIS 3.0 focuses on such health care outcomes. One such measure, which is also part of the Foundation for Accountability (FACCT), is breast cancer stage at diagnosis. Plans with good preventive health measures, that teach breast self-examination and encourage appropriate mammography, should have members whose breast cancer will be detected at an earlier, more curable stage. But gathering this information means collecting hospital charts, outpatient primary care and specialty medical records and increases the demands on all providers to gather, maintain, and report clinical information to health plans. This is only one example of the information-related demands that outcomes measures require to support value-based corporate purchasing. (6)

Sophisticated outcomes measures require detailed information on a member's health status, both before and after some medical intervention or during an episode of illness. This means surveying members directly and routinely with, for example, the "SF-36," a 36-item self-completed questionnaire that measures a member's state of health. (14) Tracking responses to this survey over time have been advocated, so that when a member becomes ill or undergoes medical treatment, the patient's subjective results can be measured by this "technology of patient experience."

Health plans and even individual physicians can then be measured by the functional results they produce. Purchasers and their beneficiaries will use this information to pick one health plan over another, and plans will use the data to determine which physicians they contract with and how they monitor, compensate, and provide incentives.

Other implications are detailed in Table 3. Essentially, each element of health care value is being addressed independently by employers to enhance the effectiveness of their purchasing.

Costs, for example, can be reduced by "carve outs," by buying each separate health care service from a competitive vendor, such as pharmacy, oncology care or radiology services, rather than taking the bundled services provided by health plans or available through local providers. Costs can also be reduced by contracting directly with providers and avoiding the overhead of health plan administration and profit, by reducing the delivery of high-cost medical care through demand management programs, and by creative financial arrangements with health plans and providers, including self-funding and risk-sharing. The other elements of value for a corporate purchaser, including employee compensation, quality, and productivity, are also likely to generate new demands on health plans and physicians as corporations drive health care to meet their purchasing objectives.

Where will it end?

The impact of this new wave of purchaser-driven demand for value and accountability is already apparent. Three broad trends are emerging:

(1.) Public Scrutiny. The public has long had a fascination with medicine. The recent adverse publicity directed at MCOs and physicians has been alternating between outcries over denial of medical services, continued escalation of costs, access to care, provider Medicare fraud, length of maternity stays, excessive corporate profits, sexual abuse of patients, and hospital billing scandals. Whether the outcry is directed against MCOs, physicians, or hospitals, public accountability for those in health care will continue to be a fact of life. Part of the result Is state regulation, resulting in activities such as legislation and publishing mortality and complication rates for medical procedures like cardiac surgery. Health plan performance is being reported to a wider audience by publications like Consumer Reports and Health Pages. (15,16) This kind of public scrutiny will increase, and the recent activities of the presidential advisory commission may well predict federal legislation and regulation in this area, which even some HMOs are advocating.

(2.) Information systems. In response to purchaser and marketplace demands, physicians, hospitals, and MCOs need to collect, analyze, and understand a tremendous amount of information. In the world of competitive value purchasing and accountability, information is the key to the health care system--sophisticated information systems will be needed to measure, manage, and report information on cost, administration, and clinical results. Simply being computer literate and automating clinical records will not be sufficient to allow physicians to shape this future. In one view, eligibility and medical records will be online, accessed by interactive systems that can bill, schedule, direct patients to specific providers, and track patient-specific clinical results. A system that reminds physicians to perform health care services, authorizes referrals and hospitalizations, and makes clinical suggestions is in the immediate future of many medical practices.

(3.) Health care organization. Health care in America is still produced as a cottage industry: physicians deliver most medical treatment in isolated office or hospital settings, independent of other providers. In much the same way that production was automated during the Industrial Revolution, health care is becoming automated and being delivered within larger organizations of physicians and hospitals, driven by purchaser requirements for value and accountability. Only within such sophisticated, integrated provider organizations can cost-responsive, information-driven systems be implemented to meet the demands of the emerging sophistication of health care purchasers. They are driving the evolution of health care towards these large-scale systems because employers are becoming unwilling to purchase anything else.

For physicians already weary and disturbed by the changes and perceived MCO demands, these trends may not paint an attractive picture. But there is also a lot to be thankful for: health care, driven by powerful new technologies, such as genetic engineering, rational drug design, and microsurgery, will have even more to offer in the future. The role of physicians in the emerging health care system will surely be different, but no less essential than today, and they may well fill the dominant roles in that system.

To do this physicians must understand the dynamics of the marketplace, anticipate the impact of emerging trends, and organize and deliver better health care results. They must also become participants in the public dialog occurring between purchasers, governmental agencies, and managed care organizations, and they must be prepared with new solutions rather than past laments. Creating a caring, effective system that makes good on the promise of better health care is impossible without the voice of the physicians who will be delivering that care. This is the time for physicians to act and to be heard.

FIGURE 2

A SAMPLE REPORT CARD

A sample report card of the type used by employers to help employees
select their health benefits. Most employers sponsor an annual employee
health plan election process during which employees select their health
plan, and perhaps contribution and benefit levels. The type of
information displayed here has been effective in directing employee
selections toward the most desirable and cost-effective choices.

                      HMO A       HMO B        Company
                                               Plan

Your monthly          $20         $25          $60
contribution

Type of HMO           IPA         Group

Membership            85,000      120,000

Overall satisfaction  89%         86%          81%

Percent of members    89%         79%          74%
would recommend

NCQA                  Full        Provisional
Accreditation

Local hospitals       St. Mary's  Memorial     Any

MD Board              88%         91%
Certification

Percent premium       84%         79%
spent on care

Wait for urgent care  24 hours    17 hours

Pediatric             78%         74%
immunization

Mammography           66%         77%

TABLE 1

THE EVOLUTION OF CORPORATE HEALTH BENEFIT PROGRAMS

Corporations have led the way in changing their employee health benefit
programs in response to challenges presented by their obligations to
shareholders and beneficiaries. As new health care system innovations
have become available, employers have increasingly incorporated these
into their benefit programs. Payers have changed to reflect these
marketplace dynamics. Similar changes are occuring in the small employer
market and governmental programs, including Medicare, Medicaid, and
CHAMPUS.

     STATE      PERIOD             FEATURES

O    Indemnity  1950s, '60s, '70s  National Blue Cross/
                                   Blue Shield commercial
                                   programs

I    Managed    1980s              Early HMOs; national POS,
     Care                          PPO programs

11   Managed    early 1990s        Local HMOs


III  Strategic  late 1990s         Carve-outs, retiree HMOs,
                Purchasing         demand management,
                                   direct provider contracting,
                                   disability management

     STATE      PROBLEMS

O    Indemnity  Lack of cost control,
                accountability


I    Managed    Quality, choice, cost
     Care

11   Managed    Value, performance
                measurement

III  Strategic  Complexity,
                coordination,
                communication

TABLE 2

PURCHASER-MANDATED MEASURES AND THEIR IMPACT ON PHYSICIANS

Although these measures are directly imposed on health plans, improving
results is only possible if health plans impact physicians' professional
activities.

Requirement           Measure

NCQA accreditation    Credentialing




                      Preventive Health
                      Services


                      Medical Records



                      Quality
                      Improvement


HEDIS                 Quality of care



                      Access measures



                      Employer-specific
                      utilization



                      Board certification


Satisfaction surveys  Health plan satisfaction


                      Physician-specific
                      measures



Report cards          Favored hospitals



                      Percent of open panels



                      Access


Requirement           Demands on Physicians

NCQA accreditation    Documentation of licensure,
                      board certification, medical
                      school, residency, malpractice
                      history

                      Conformance to HMO protocols
                      and committee work to update
                      guidelines and review results

                      HMO personnel required to
                      perform office reviews of
                      patient records

                      Participation HMO studies,
                      supply patient records,
                      committee work to review

HEDIS                 Office review of patient
                      records, patient contact
                      by HMO, mandated procedures

                      Measurement of appointment
                      schedule delays and office
                      wait durations.

                      Office records may have to
                      include employer in billing
                      and encounter information
                      to HMO

                      Potential elimination of
                      unboarded physicians

Satisfaction surveys  Results used to sanction
                      and reward physicians

                      Satisfaction profiles
                      may impact reimbursement,
                      recredentialing, and
                      continued contracting

Report cards          Unpopular hospitals shunned
                      and physicians praticing
                      there penalized

                      Physicians may be restricted
                      from closing practice to new
                      HMO patients

                      Physicians may have to
                      prolong office hours.

TABLE 3

THE IMPACT OF VALUE-BASED PURCHASING ON HEALTH CARE DELIVERY

As health care purchasers address each purchasing element in their drive
to improve the value of the health benefits they provide, there are
significant impacts on MCOs and practicing physicians.

Purchasing    Possible results

Cost          Carve-outs

              Direct contracting


              Demand management


              Risk sharing

              Self-funding

Compensation  Employee contribution

              Physician incentives


              Employer marketing to
              employees

Quality       Outcome measures

              Health status indicators

              Case management

              Increased information
              system demands

Productivity  Managed disability


              24 hour programs


              Wellness


Purchasing    Physician implications

Cost          Diagnostic and specialty care fragment

              Greater assumption of risk for
              physicians

              Patient self-medication and -referral;
              conflicts between patient, MD, and HMO

              Unregulated financial liabilities

              Employer involvement in patient care

Compensation  Inadequate coverage

              Impact on credentialing, contracting
              and capitation

              Potential disruption of physician-
              patient relationships

Quality       Profiling, credentialing

              Increased record keeping

              Increased administrative activities

              Investment in sophisticated offfice
              systems, computerized patient records

Productivity  Participation in workers'
              compensation care

              Integration of health and workers'
              compensation records

              Demand management, increased telephone,
              mail, and personal communications

Acknowledgment

The author would like to thank Armando Baez and Vicki Sharp, RN, MBA, for their generous contributions and review of this material.

References

(1.) Freundhelm, M. The physician's view when managed care cornea to town. NY Times. June 14, 1992: F4.

(2.) Feldstein, PR. The Politics of Health Legislation: An Economic Perspective. Ann Arbor, MI: Health Administration Press; 1988.

(3.) Schwartz, WB and Mendelson. DN. "Hospital cost containment In the hard lessons learned and prospects for the 1990s." New England Journal of Medicine. 1991; 324(15): 1037-1042.

(4.) Winslow, R. "Employer group rethinks commitment to big HMOs." Wall St J. July 21, 1995: A1.

(5.) Foundation for Accountability. Guidebook for Performance Measurement. Jackson Hole, WY: May 1995.

(6.) The quest for accountability. Special Report, Business & Health. 13(12). Suppl.: E6-30.

(7.) Iglehart, JK. Managed competition. New England Journal of Medicine. 1993: 328(16):1208-1212.

(8.) National Committee for Quality Assurance, Washington, DC: 1995.

(9.) HEDIS 2.5. National Committee for Quality Assurance, Washington. DC: 1995.

(10.) Annual Member Health Care Survey. National Committee for Quality Assurance. Washington, DC: 1995.

(11.) Coulter, CH. An integrated vision of managed care. Tallon. R., ed., Critical Concepts in Medical Practice Management. New York, NY: McGraw-Hill; 1996.

(12.) Wallich, P. Invasion of the bean counters: physician profiles--the good, the bad and the unadjusted. Sci Am. 1995;273(l):33-36.

(13.) Welch, WP, Miller. ME et al. Geographic variation In expenditures for physicians' services in the United States. New England Journal of Medicine. 1993:328(16):621-7.

(14.) Ware, JE and Sherbourne. CE. The SF-36 short-form health status survey: I. conceptual framework and item selection." Medical Care. 1992;30(6):473-483.

(15.) How good is your health plan? Consumer Reports. 1996;61(8):28-42.

(16.) Health Pages. 135 Fifth Ave.. New York, NY. 1995.

Christopher H. Coulter, MD, MPH,

FACPE, is the Executive Director of UltraLink, LLC, in Costa Mesa, California, a national health plan administration organization serving Fortune 500 corporations. He can be reached by calling 714/427-5513 or via email at [e-mail].