Step right up: In the competition among health plans for popularity and enrollment growth, PPOs are attracting bigger crowds. (Life/Health).

CareFirst Blue Cross Blue Shield knows how to pick a winner. The company, which serves customers in Maryland, Delaware, northern Virginia and Washington, D.C., was the first carrier in its region to offer a preferred-provider organization Since 1996, its PPO membership has doubled, increasing by more than 600,000 individuals.

Health maintenance organizations, the enrollment darlings of the 1980s and early- to mid-'90s, are losing members in what is being called the "decade of the PPO." Unlike HMOs, which require that individuals see a primary-care physician, remain in network for coverage and obtain referrals prior to seeing specialists, PPOs allow members to see providers both within and outside a network.

Today, an estimated 100 million people in the United States belong to PPOs, which enroll far more members than do HMOs and are growing at a more rapid rate, according to the National Committee for Quality Assurance, a nonprofit organization that evaluates and reports on the quality of managed-care organizations.

The cost gap that once drove some employers to forgo PPOs for less expensive HMO products is now narrowing, and many insurers are confident that the trend of PPO enrollment growth will continue. HMOs remain in the fray, however, and to compete, they are adopting many features found in PPO-style plans.

On the Rise

PPO enrollment has increased to 48% of all workers' health insurance from 35% just three years ago, according to a survey commissioned by the Henry J. Kaiser Family Foundation, a nonprofit organization focused on major health care issues. HMO membership declined to 23% from 27% during the same period.

Location and company size are key factors in enrollment patterns of the health-care models. While HMOs continue to dominate the western United States, with 42% of the market, compared with 29% nationally, PPOs have a greater market share in northeastern and mid-Atlantic states. HMOs have the largest market share (37%) among businesses with more than 5,000 employees, while PPOs have nearly one-half the market share in all firm sizes, except the smallest and largest companies.

Humana is another commercial carrier that has seen a steady rise in PPO enrollment over the past several years. As of November, Humana had more than 1.2 million members enrolled in some type of PPO product. "I think a PPO is a good fit for many consumers, because it allows them to access the provider of their choice and take advantage of arrangements we have with them," said Beth Bierbower, vice president of product development for the Louisville, Ky.-based organization.

Reasons for Growth

More choices, freedom from having to obtain services within a network and greater flexibility are the main reasons nonrestrictive PPOs have become the clear-cut leaders among health-care models today.

Unfulfilled promises made by HMOs to offer more choices and better standards of care also have contributed to the rise in PPO enrollment. "HMOs started with a lot of promise in the mid- to late '70s that preventative care and a range of prevention techniques would allow providers to take better care of patients," said Jim Jacobson, a partner with Holland and Knight's National Health Law Group in Boston. But HMOs haven't fulfilled that promise because the focus shifted in the 1980s from preventative care to cost-containment methods, he said.

The consumer backlash against managed care and negative publicity surrounding HMOs have been linked to the model's decline. People find the word "managed" and the concept of health care being controlled unfavorable, said Barbara Benevento, senior vice president for health business for Blue Cross Blue Shield of Florida.

"People like PPOs because managed care hasn't worked," said Barry Scheur, chairman of Boston-based The Oath Inc., a private equity corporation that acquires distressed and undervalued provider-owned HMOs. "It doesn't mean it can't work; it just doesn't work."

"Primary-care physicians participating in managed-care plans often operate like mills, rushing patients through visits with barely enough time for the patient to ask questions," Jacobson said. This is because managed-care reimbursements (capitation, withholds, bonuses/penalties) typically provide a financial incentive to primary-care physicians, and even many specialists, to restrict or withhold care coordination, follow-up care, referrals to other providers and even the physician's own time with the patient, he said. "The more patients the PCP sees under managed care, the more money he or she makes, but unfortunately, the poorer quality care the patient receives?' The key to turning around this perverse incentive is to transpose cost-containment incentives into quality incentives, but only a few HMOs have taken that leap of faith, he added. PPOs, on the other hand, do not usually capitate physicians or provide other incentives to withhold care.

Much of the success of PPOs was fueled by the Blue Cross Blue Shield system, particularly with the creation of its Blue Card Program, said Joseph Berardo, chief marketing officer of the preferred-provider organization MultiPlan Inc. The electronic program allows national employers, regardless of where they live or work, access to Blue Cross Blue Shield providers. "Because you have success of the Blues in most markets, other commercial and regional carriers developed a lot of products to compete with the broad network of BCBS," he said. MultiPlan has created network solutions and programs that compete directly with the BCBS Blue Card Program on a regional and national basis. These programs include a Triple Option Program, which comprises a three-tiered approach to coverage, and MultiPlan Plus, a program offering clients more enhanced product offerings in targeted geographic areas.

Closing the Gap

The anticipated double-digit rise in health-care costs is likely to bolster the popularity of PPO plans. Increases of 13% to 16%, depending on the type of health plan, are projected to hit the industry soon, according to Hewitt Associates LLC, a global management consulting and outsourcing firm. Hewitt projects the average health plan will cost $5,524 per employee this year, up from $4,778 in 2001. In addition, employees will pay between $186 and $463 per month for health coverage this year.

Global consulting firm Watson Wyatt predicts that health-care companies' increases will be greater than originally expected for many corporate-benefit plans this year, due to the recessionary environment and the impact of the Sept. 11 catastrophe. Watson Wyatt expects to see corporate health-care benefit costs increase by more than 15% this year.

"The days of HMOs' competitive advantage in the market through pricing is now a thing of the past' said Alan Katz, senior vice president of individual and small group sales for WellPoint in Thousand Oaks, Calif.

In 2000, employers reported for the first time a greater increase in the average cost of their HMO plans than in PPO models, up from 7.7% to 9.6%, according to the American Association of Preferred Provider Organizations. The gap between the costs of covering an employee through an HMO and through a PPO narrowed to about $300, and HMO plan sponsors are paying now for the deep discounts of 1996 and 1997.

According to the association, factors that have a greater impact on HMO costs and are contributing to the counterintuitive trend include:

* higher administrative overhead;

* tougher negotiating by providers on both reimbursement and compliance with administrative requirements; and

* HMO populations that are less healthy

PPOs are actually growing in cost at a slower rate than HMOs, said Randall Abbott, a senior consultant with Watson Wyatt. For years, most PPO and point-of-service plans had annual cost increases of 6% to 8%. During the last two years, however, the rate was significantly higher, he said. In a recent survey, Watson Wyatt found that employers expected their health-care costs in 2001 to go up 13.6%, with indemnity plans projected to increase about 14.4%, HMOs 13.9% and PPOs 13.7%. "This is showing that the gap in cost escalation between the two models--PPOs and HMOs--has now virtually eroded," said Abbott.

Geography is also a factor in the cost differential between the two products. In the West, HMOs offer significantly lower costs, according to the association. But there is little difference in costs between the models in midwestern states.

As the traditional underwriting cycle, which in broad terms means three years of profitable growth followed by a three-year downturn, reasserts itself, health plans are seeing the need to increase rates rapidly on all products to keep up with medical cost increases, said WellPoint's Katz, who added that the industry is currently in an upside of the cycle. HMOs, in many ways, have been the hardest hit by the cycle, because they offer rich benefits and are being weaned from capitation, he said. Also, providers are pushing more risk back onto managed-care companies. As a result, HMO rate increases are in many cases surpassing those of PPOs, Katz said.

While PPO costs remain a bit higher than those of HMOs, consumers' desire for choices takes precedence over paying slightly higher prices. A recent Mercer/Foster Higgins study found that while HMO costs are $267.90 per employee per month on average, PPOs have been able to offer high-quality care with choices for the consumer for only $291.17 per month per employee.

HMOs' Transformation

To compete with the open accessibility and freedom of choice offered by PPO products, HMOs are changing portions of their requirements to parallel PPO plan offerings.

In the past, HMOs tried to become more like PPOs through point-of-service plans, which allow members to go outside the HMO network. "HMOs created these plans in direct opposition to PPO growth," said Ken Linde, chief executive officer of Bethesda, Md.-based Destiny Health, a privately held insurance company. Destiny offers a health plan that allows members to keep the money in their personal medical funds if they leave the plan rather than the "use-it-or-lose-it" proposition found in traditional PPOs. While some consumers found point-of-service plans a favorable alternative to PPOs, most preferred PPO products because the plans paid more in fee schedules without nearly as many restrictions, Linde said.

"Many HMO companies are now scrambling to come up with PPO strategies and plans," said WellPoint's Katz. Over the past several years, WellPoint has shifted many of its products into hybrid plans, which combine elements of HMOs, such as preventative-care mechanisms, and PPO strategies, such as high-cost sharing and coinsurance. WellPoint customers are expressing increased interest in these plans.

In addition, many HMOs have lifted referral requirements and taken on a more "open access" approach by doing away with requirements that members must select a primary-care physician, or gatekeeper. Humana recently changed its Humana/ChoiceCare Plan HMO by lifting referral requirements and allowing members to go directly to any specialist within the network.

Blue Shield of California, based in San Francisco, added direct access to specialists in its HMO in 1997 so members can see a specialist in a medical group or individual physician practice organization by paying a $30 copay. "Our perspective was that we should be bringing innovations to the HMO in order to meet consumers' needs," said Ken Wood, executive vice president and chief operating officer.

Some observers believe there eventually will be a blending of the two products. "Five years from now, if someone talks about HMOs and PPOs, it may be unclear as to what is being talked about, because the models will have blended enough so that those kinds of labels will be less meaningful," said WellPoint's Katz. Instead, the blended plans will feature a tradeoff between fixed costs (premiums) and variable costs (out-of-pocket costs), as well as between benefits and coverage designs that promote preventative care, often found in HMO products, and benefits in which going to a particular provider will be less costly to members, he said.

Some insurers, however, believe HMOs will not transform into more PPO-like products, but will remain one of many separate portfolio choices offered to consumers. When Blue Cross Blue Shield of Florida recently removed several restrictions, including mandatory authorization and referral requirements, from its HMO products, the result was a dramatic rise in costs, Florida Blues' Benevento said. As a result, the Florida Blues is now offering customers a Platform for Affordable Choices, which comprises a series of options with similarities to previous HMO offerings, as well as PPO products, that are designed to best fit the individual's family and personal needs.

Equal Satisfaction

According to a recent Consumer Reports survey, HMO respondents were just as satisfied with their health plan as those in PPOs, even when asked about their choice of doctors and care from physicians. Overall, 57% of respondents in PPOs and 55% in HMOs said they were highly satisfied with their managed-care plan.

"While we have all heard the horror stories about HMOs, consumer-satisfaction scores still support that customers with HMOs are very satisfied with their coverage, just as they are with their plans;' said Rita Costello, senior vice president of strategic marketing and analysis for CareFirst Blue Cross Blue Shield.

PPO satisfaction lies more with service, such as claims processing and administrative functions, while HMO satisfaction is more centered on access to care, including navigating referral processes and getting to see physicians, said Blue Shield of California's Wood.

"HMO enrollment is likely to continue to decline, but some people--those who like the more paternalistic approach of HMOs--will still seek them out, and those consumers looking for flexibility, control and choice will seek out PPOs," said Katz of WellPoint. Both will be able to find what they're looking for, and both will find an equal level of satisfaction, he added.

Some insurers, however, believe consumers' satisfaction with PPOs is continuing to come out ahead of HMOs. "Satisfaction is much greater in PPO-type plans because consumers are more involved and aware of what's going on with their care;' said Linde of Destiny Health.

Continued Winner?

While some insurers believe the cycle may eventually lead to a resurgence for HMOs, most are confident that the next few years will remain the "decade of the PPO."

"I wouldn't be surprised to see HMOs gain some market share in the future as the issue of cost continues to escalate and makes more restrictive plans attractive again," said Dr. Mark Banks, president and CEO of Blue Cross Blue Shield of Minnesota. But the flexibility and choices of PPOs will keep them growing for quite some time, he added.

"PPOs are definitely here to stay," said Watson Wyatt's Abbott, who believes consumers' continued interest in a nongatekeeper-type approach, like a PPO or more open-access style products, will bolster PPOs' stronghold as a leader in health plan choice.

"I think consumers' messages have come across loud and clear--they want freedom of choice--and PPOs will continue to grow and prosper in offering them that choice" said Humana's Bierbower.

PPOs will likely see changes, however, including the possibility of becoming more highly regionalized, and not state specific, said CareFirst's Costello. In addition, she said the next-generation PPO will be more select than today's models. "It won't just be about cost, but also about performance, which in the end equates to customer satisfaction and positive outcomes."

Health Plan Enrollemnt for Covered Workers, by Plan Type, 1988-2000

          Conventional  HMO  PPO  POS

1988          73%       16%  11%
1993          46%       21%  26%   7%
1996          27%       31%  28%  14%
1998 (*)      14%       27%  35%  24%
1999 (*)       9%       28%  38%  25%
2000 (*)       8%       29%  41%  22%

(*)Distribution is statistically different from the previous year for
years 1996-1998, 1998-1999, 1999-2000.

Source: The Henry J. Kaiser Family Foundation, Menlo Park, Calif.
Financial Trends, Health Maintenance Organizations All Model
Types--1996-2000

($ Thousands)




                                                           2000

Financial Development ($)

Assets                                               49,207,522
Net Worth                                            14,266,997
Total Premiums                                      165,456,498
Total Revenues                                      168,461,549
Net Income                                            1,095,247

Enrollment Data

Group                                                62,627,607
Medicare Risk                                         6,150,568
Medicare Cost                                           271,108
Medicaid                                             12,030,438
Individual                                              992,267
Other                                                 2,424,341
Total Members End of Year                            84,496,338
Member Months                                       989,978,708
% Change in Member Months                                   0.3
Number of Participating Physicians                    2,945,028

Utilization

Physician Visits Per 1,000 Members                        4,795
Nonphysician Visits Per 1,000 Members                     1,665
Total Hospital Patient Days Per 1,000 Members               357
Commercial Hospital Patient Days Per 1,000 Members          232
Medicare Hospital Patient Days Per 1,000 Members          1,607
Medicaid Hospital Patient Days Per 1,000 Members            365
Total Inpatient Costs Per Day (S)                         1,459




                                                           1999

Financial Development ($)

Assets                                               46,050,337
Net Worth                                            12,827,835
Total Premiums                                      152,956,793
Total Revenues                                      155,502,823
Net Income                                             -138,244

Enrollment Data

Group                                                62,609,297
Medicare Risk                                         6,672,775
Medicare Cost                                           301,026
Medicaid                                             10,530,239
Individual                                            1,060,387
Other                                                 2,807,796
Total Members End of Year                            83,981,555
Member Months                                       987,279,472
% Change in Member Months                                   2.7
Number of Participating Physicians                    2,873,476

Utilization

Physician Visits Per 1,000 Members                        4,558
Nonphysician Visits Per 1,000 Members                     1,572
Total Hospital Patient Days Per 1,000 Members               339
Commercial Hospital Patient Days Per 1,000 Members          213
Medicare Hospital Patient Days Per 1,000 Members          1,485
Medicaid Hospital Patient Days Per 1,000 Members            421
Total Inpatient Costs Per Day (S)                         1,381




                                                           1998

Financial Development ($)

Assets                                               41,768,825
Net Worth                                            11,474,056
Total Premiums                                      135,089,150
Total Revenues                                      142,769,853
Net Income                                           -1,258,833

Enrollment Data

Group                                                62,363,688
Medicare Risk                                         6,006,361
Medicare Cost                                           392,404
Medicaid                                              9,789,567
Individual                                            1,642,172
Other                                                 2,107,940
Total Members End of Year                            82,302,122
Member Months                                       958,568,521
% Change in Member Months                                  13.8
Number of Participating Physicians                    2,666,919

Utilization

Physician Visits Per 1,000 Members                        4,304
Nonphysician Visits Per 1,000 Members                     1,364
Total Hospital Patient Days Per 1,000 Members               326
Commercial Hospital Patient Days Per 1,000 Members          213
Medicare Hospital Patient Days Per 1,000 Members          1,475
Medicaid Hospital Patient Days Per 1,000 Members            350
Total Inpatient Costs Per Day (S)                         1,360




                                                           1997

Financial Development ($)

Assets                                               36,877,634
Net Worth                                            10,542,076
Total Premiums                                      117,544,967
Total Revenues                                      120,571,031
Net Income                                             -840,714

Enrollment Data

Group                                                57,092,926
Medicare Risk                                         5,004,179
Medicare Cost                                           434,656
Medicaid                                              7,993,108
Individual                                            1,595,803
Other                                                 2,303,787
Total Members End of Year                            74,424,476
Member Months                                       845,804,047
% Change in Member Months                                  12.0
Number of Participating Physicians                    2,478,256

Utilization

Physician Visits Per 1,000 Members                        4,005
Nonphysician Visits Per 1,000 Members                     1,262
Total Hospital Patient Days Per 1,000 Members               318
Commercial Hospital Patient Days Per 1,000 Members          219
Medicare Hospital Patient Days Per 1,000 Members          1,409
Medicaid Hospital Patient Days Per 1,000 Members            374
Total Inpatient Costs Per Day (S)                         1,283




                                                           1996

Financial Development ($)

Assets                                               32,644,741
Net Worth                                            10,891,167
Total Premiums                                      102,057,517
Total Revenues                                      104,604,036
Net Income                                              436,261

Enrollment Data

Group                                                52,359,083
Medicare Risk                                         4,197,531
Medicare Cost                                           454,790
Medicaid                                              6,558,908
Individual                                            1,336,968
Other                                                 2,612,688
Total Members End of Year                            67,519,963
Member Months                                       755,496,713
% Change in Member Months                                   ...
Number of Participating Physicians                    2,134,067

Utilization

Physician Visits Per 1,000 Members                        3,719
Nonphysician Visits Per 1,000 Members                     1,164
Total Hospital Patient Days Per 1,000 Members               308
Commercial Hospital Patient Days Per 1,000 Members          219
Medicare Hospital Patient Days Per 1,000 Members          1,314
Medicaid Hospital Patient Days Per 1,000 Members            392
Total Inpatient Costs Per Day (S)                         1,363

                                                           4-Year
                                                       Compounded
                                                    Annual Growth
                                                         Rate (%)

Financial Development ($)

Assets                                                       10.8
Net Worth                                                     7.0
Total Premiums                                               12.8
Total Revenues                                               12.7
Net Income                                                   25.9

Enrollment Data

Group                                                         4.6
Medicare Risk                                                10.0
Medicare Cost                                               -12.1
Medicaid                                                     16.4
Individual                                                   -6.2
Other                                                        -1.9
Total Members End of Year                                     5.8
Member Months                                                 7.0
% Change in Member Months                                     ...
Number of Participating Physicians                            8.4

Utilization

Physician Visits Per 1,000 Members                            6.6
Nonphysician Visits Per 1,000 Members                         9.4
Total Hospital Patient Days Per 1,000 Members                 3.8
Commercial Hospital Patient Days Per 1,000 Members            ...
Medicare Hospital Patient Days Per 1,000 Members              ...
Medicaid Hospital Patient Days Per 1,000 Members              ...
Total Inpatient Costs Per Day (S)                             ...
Financial Trends, Health Maintenance Organizations, Nonprofit Model
Type--1996-2000

($ Thousands)




                                    2000         1999         1998

Financial Development ($)

Assets                        18,999,562   18,060,229   16,597,694
Net Worth                      5,411,866    4,907,259    4,741,357
Total Premiums                57,101,899   53,913,736   44,436,972
Total Revenues                58,107,575   54,915,576   49,378,340
Net Income                       539,214     -542,455     -711,722

Enrollment Data

Group                         21,720,889   22,552,535   21,961,949
Medicare Risk                  1,803,136    2,206,074    1,663,715
Medicare Cost                    213,003      252,669      325,667
Medicaid                       4,461,768    3,548,133    2,990,847
Individual                       396,657      433,294      935,576
Other                            408,051      477,220      611,841
Total Members End of Year     29,003,503   29,469,934   28,489,582
Member Months                340,417,600  343,900,867  332,962,571
% Change in Member Months           -1.0          3.4          8.7
Number of Participating          651,860      596,460      546,501
Physicians

Utilization

Physician Visits Per 1,000         4,253        4,519        4,328
Members
Nonphysician Visits Per            1,723        1,825        1,733
1,000 Members
Total Hospital Patient Days          317          305          303
Per 1,000 Members
Commercial Hospital Patient          222          201          204
Days Per 1,000 Members
Medicare Hospital Patient          1,406        1,367        1,269
Days Per 1,000 Members
Medicaid Hospital Patient            311          358          406
Days Per 1,000 Members
Total Inpatient Costs Per          1,519        1,437        1,365
Day ($)

                                                              4-Year
                                                          Compounded
                                                       Annual Growth
                                    1997         1996       Rate (%)

Financial Development ($)

Assets                        15,122,883   13,585,761            8.7
Net Worth                      4,727,378    4,583,929            4.2
Total Premiums                41,746,754   36,750,510           11.6
Total Revenues                42,848,110   37,629,333           11.5
Net Income                      -344,209       90,803           56.1

Enrollment Data

Group                         20,486,503   18,880,939            3.6
Medicare Risk                  1,317,561    1,085,305           13.5
Medicare Cost                    355,135      372,551          -13.0
Medicaid                       2,941,607    2,322,704           17.7
Individual                       896,346      722,998          -11.8
Other                            499,316      908,360          -18.1
Total Members End of Year     26,496,468   24,292,856            4.6
Member Months                306,356,247  276,957,144            5.3
% Change in Member Months           10.6          ...            ...
Number of Participating          462,823      391,239           13.6
Physicians

Utilization

Physician Visits Per 1,000         4,016        4,015            1.4
Members
Nonphysician Visits Per            1,687        1,754           -0.4
1,000 Members
Total Hospital Patient Days          282          281            3.1
Per 1,000 Members
Commercial Hospital Patient          203          213            ...
Days Per 1,000 Members
Medicare Hospital Patient          1,202        1,114            ...
Days Per 1,000 Members
Medicaid Hospital Patient            364          392            ...
Days Per 1,000 Members
Total Inpatient Costs Per          1,418        1,422            ...
Day ($)
Financial Trends, Health Maintenance Organizations, For-Profit Model
Type--1996-2000

($ Thousands)




                                    2000         1999         1998

Financial Development ($)

Assets                        30,207,960   27,990,107   25,171,131
Net Worth                      8,855,130    7,920,576    6,732,699
Total Premiums               108,354,599   99,043,058   90,652,178
Total Revenues               110,353,973  100,587,247   93,391,513
Net Income                       556,033      404,211     -547,111

Enrollment Data

Group                         40,906,718   40,056,762   40,401,739
Medicare Risk                  4,347,432    4,466,701    4,342,646
Medicare Cost                     58,105       48,357       66,737
Medicaid                       7,568,670    6,982,106    6,798,720
Individual                       595,610      627,093      706,596
Other                          2,016,290    2,330,576    1,496,099
Total Members End of Year     55,492,835   54,511,621   53,812,540
Member Months                649,561,108  643,378,605  625,605,950
% Change in Member Months            1.0          2.3         16.7
Number of Participating        2,293,168    2,277,016    2,120,418
Physicians

Utilization

Physician Visits Per 1,000         5,078        4,579        4,292
Members
Nonphysician Visits Per            1,634        1,436        1,168
1,000 Members
Total Hospital Patient Days          378          357          338
Per 1,000 Members
Commercial Hospital Patient          237          219          217
Days Per 1,000 Members
Medicare Hospital Patient          1,695        1,541        1,567
Days Per 1,000 Members
Medicaid Hospital Patient            397          454          325
Days Per 1,000 Members
Total Inpatient Costs Per          1,432        1,356        1,357
Day ($)

                                                              4-Year
                                                          Compounded
                                                       Annual Growth
                                    1997         1996       Rate (%)

Financial Development ($)

Assets                        21,754,752   19,058,980           12.2
Net Worth                      5,814,698    6,307,238            8.9
Total Premiums                75,798,213   65,307,008           13.5
Total Revenues                77,722,921   66,974,703           13.3
Net Income                      -496,505      345,459           12.6

Enrollment Data

Group                         36,606,423   33,478,144            5.2
Medicare Risk                  3,686,618    3,112,226            8.7
Medicare Cost                     79,521       82,239           -8.3
Medicaid                       5,051,501    4,236,204           15.6
Individual                       699,457      613,970           -0.8
Other                          1,804,471    1,704,328            4.3
Total Members End of Year     47,928,008   43,227,107            6.5
Member Months                539,447,800  478,539,569            8.0
% Change in Member Months           12.7          ...            ...
Number of Participating        2,015,433    1,742,828            7.1
Physicians

Utilization

Physician Visits Per 1,000         3,998        3,548            9.4
Members
Nonphysician Visits Per            1,021          823           18.7
1,000 Members
Total Hospital Patient Days          338          323              4
Per 1,000 Members
Commercial Hospital Patient          228          223            ...
Days Per 1,000 Members
Medicare Hospital Patient          1,507        1,411            ...
Days Per 1,000 Members
Medicaid Hospital Patient            381          392            ...
Days Per 1,000 Members
Total Inpatient Costs Per          1,219        1,333            ...
Day ($)

Source: A.M. Bests Aggregates & Averages HMO, United States, 2001
Edition.