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specIal repOrt: INtegratIVe MedIcINe IN the Marketplace
Marketplace Dynamics: Implications for Integrative Providers
Stephen Bolles, DC
hile recent headlines trumpet health care reform for focusing on revising elements of the delivery and compensation systems, in fact, the transactional part of our health system already had been undergoing substantial evolution. New health care products have dramatically altered insurance coverage models, and health plan subscribers are being thrust into a new role—one resembling that of retail consumers. Providers, however, have not been adequately prepared for this shift, and, although some nonmedical professions have grown and become established outside of health-plan coverage, there still is a need for an ongoing conversation about how the retail health care marketplace will affect integrative practitioners.
Health Care Marketplace Dynamics and the Taxonomy of Dominance
Second, until recently, the demand side (consumers) has not had any real marketplace power. Further, consumers have not exhibited any real awareness of the consequences of medical utilization or values, such as outcomes per unit of service and delivery cost. The supply side (providers) has been able to essentially establish, in market terms, an exclusive set of products with no competition.
Cracks in the Armor of Health Care Provision
Viewed from the perspective of retail marketplace dynamics, the American health care system is a curious animal. Although in most retail markets supply and demand are in a state of constant and interdependent tension in which demand encourages and supports supply-side innovation, health care has historically inverted that dynamic. In contrast to retail markets, health care in America developed with the supply side able to dictate to the demand side what was available, with no practical competitive pressures to force innovation and efficiency. Hence, until recently, consumers have been protected from needing—or even being able—to make discriminating choices, so the kind of information retail consumers would generally expect has not been available. It is only now that information about price and quality, along with decision-support tools to compare and contrast options, is slowly beginning to make its way into the market for consumers to use. Up to this point, the validity, wisdom, and effectiveness of this medical variation to retail marketplace design has essentially gone unchallenged. Due to the cultural dominance and politics of mainstream medicine, no profession or organization has been able to amass the required evidence or achieve sufficient public visibility to challenge medicine’s supply-side dominance, even in the face of often compelling clinical research that clearly shows some medical community practices to be wrong, ineffective, or even dangerous.1(p514) This situation has been possible for at least 2 reasons. The first is because medical education has had the ability to deeply inculcate its own cultural values through the training of its practitioners. Until the late 1980s, when the chiropractic profession won a landmark antitrust lawsuit against the American Medical Association, there was no way to effectively challenge the biased information being taught in medical schools and reinforced by the medical culture in practice.
One of the more arresting aspects of David Eisenberg’s original 1993 study on complementary and alternative medicine (CAM) use2 was the finding that suggested more than half of respondents using alternative medicine were not telling their physicians what they were doing. When reexamined some years later,3 this behavior was intact. No evidence shows the behavior has changed since, though it has arguably become an even more pervasive position that patients—as consumers of health care services and information—take with providers. This position is especially evident when considering the profound shift in older Americans’ behavior in this respect. Whereas this population used to be the most reliable reporters of their health practices to physicians, a 2007 survey showed they have shifted to being a population least likely to be voluntary reporters, withholding significant information from their doctors unless specifically asked.4 Another phenomenon that has contributed to health care’s changing marketplace has to do with the shifts in health insurance products. Health care benefits that health plans develop, promote, sell, and manage, for example, began to change in character about 10 years ago when it became clear that managed care had not been able to deliver on its promise to control escalating costs. Early changes included shifting some aspects of financial responsibility and decision making onto consumers, with never-before-experienced options among deductibles, choices between provider networks, and variable copay levels. This menu of options has continued to increase, with providers handing off the responsibilities of choice to consumers. In contrast to the former, paternalistic system, these increased options may feel to the consumer like an abdication of guidance and support. This is especially true when consumers chose highdeductible health plans in which they have much more responsibility for managing health expenses; health plans have made these products available with very little in the way of decisionsupport tools for how to most effectively choose health care services across the wide spectrum of cost and quality. Originally heralded by the imposition of copay responsibilities when health costs began to escalate rapidly in the 1980s, the bliss of benign disengagement that consumers had been able
Integrative Medicine • Vol. 9, No. 5 • Oct/Nov 2010
Bolles—Integrative Medicine in the Marketplace
Accessed July 30. consumers paid a deductible amount on the front end then had costs covered in such a way that they rarely knew—or had to care—about health expenses after that. and an overall greater proportionate amount of patient fiscal sponsorship and responsibility. this is an inexorable trend. most consumers can no longer maintain any sense of detachment from health care finances. but the financial bar for most families is much. a response to uncontrolled rising costs and an inability on employers’ parts to continue to absorb these costs on behalf of their employees. At heart. An HSA is a tax-advantaged medical savings account available to employees who are enrolled in an HDHP. based on “stop loss” coverage for “catastrophic events. CDHP deductible amounts are larger than the “front end” deductibles that older insurance plans provided. higher copays. placing them on the hook for claims costs until a defined threshold is reached. such as an office visit. then exposed to the substantial uncertainty of health care costs after their employer-sponsored “budget’ (the services covered as the “benefit” provided for employees) has been exhausted. with shrinking benefit sets. but interest on the account is not subject to federal income tax. 9.wikipedia. This change in benefit design has had 2 principal effects. rather than seeing a deductible as something to “get through” to the point where coverage kicks in—at that point enjoying the sense of safety that this arrangement conveys—consumers in these plans are now protected initially. Examples of other health plan product tools are shown in the Table. Based on the degree of market penetration these benefits products have accomplished in a short time. a relatively seamless process. An HDHP is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. No. Save for the few individuals who still enjoy highly compensated benefits packages. When their expenses satisfied the deductible. the consumers move into paying their deductibles. procedure. An FSA allows an employee to contribute to a pre-tax account that can be used to pay for certain IRS-approved medical expenses. or CDHPs. the benefit now commonly comes first and then the deductible. As an example. insurance kicks back in. Since then. An HMO is a prepaid type of fee for service where care costs are capped or budgeted. If expenses exceed that deductible. straining and breaking family finances. the sense of protection and safety that consumers feel continues to evaporate. In the health insurance and the health care industry. The sense of protection many used to feel with older insurance plans in which patients were inured to the costs of care has been replaced with a sense of being threatened by the lack of any clear sense of control in purchasing decisions. so family budgets have to absorb greater amounts of costs— commonly. In an HSA. The second is emotional. Once the benefit is exhausted. an older insurance plan might have offered a $2000 deductible that a family could budget for and amortize over a calendar year. Available at: http://en. Flexible spending account (FSA). Withdrawals for nonmedical expenses are treated very similarly to those in an individual retirement account in that they may provide tax advantages if taken after retirement age and they incur penalties if taken earlier. much higher than before. In the old model. the benefits of the health plan would kick in. many more thousands of dollars per year. these newer plans initially provide the contract benefit. The funds contributed to the account can be either pretax or posttax. employers can either fund a pretax Table. normally paired with high-deductible health plans (HDHPs). and the family would essentially never need to see another bill for the year. Tools such as health savings accounts (HSAs) support this type of product. New Products. test. covering a set amount of health expenses. HSAs are owned by the individual and funds roll over and accumulate year to year if not spent.org. also called 125 plans (their designation with the Internal Revenue Service) or Flex Plans Health maintenance organizations (HMOs) Health savings account (HSA) High-deductible health plan (HDHP) Preferred provider organizations (PPOs) Definitions are adapted from Wikipedia. fee for service involves doctors and other health care providers receiving a fee for each action provided. An FSA is 1 of a number of tax-advantaged financial accounts that can be set up through a cafeteria plan of an employer in the United States. Bolles—Integrative Medicine in the Marketplace Integrative Medicine • Vol. New Roles The New Consumer The current product version of this trend is the euphemistically termed consumer-directed health plans.” In the new world. these are revised transactional processes in which consumers have a model of insurance protection that is an inverted form of what was customary for more than 50 years. In many CDHPs. This is a “use-or-lose” account where any money not spent by the end of the plan year will be forfeited.to enjoy began to dissipate. Health Care Product Definitions Health Care Product Consumer-directed health plans (CDHPs) Fee for service Characteristics A class of benefits products that have an orientation toward consumer choice. Unlike an FSA. 2010. 5 • Oct/Nov 2010 21 . or other health care service. Coverage still exists after that deductible is satisfied. a much higher dollar figure ($5000 to $10 000) is not uncommon. Instead of the deductible being used first. PPOs are normally networks of those who provide services at contractually-defined discounts from “list” fees. increasing deductibles. The first is financial.
5 This figure had risen from 38% in 2001. cost effectiveness–based arguments. From their point of view. and comparison shopping tools are coming on the market that help people make choices on the same basis they make other retail choices—a sense of value. the market that most are used to is not really one of insurance per se. Figures from Pew Research in 2007 quantified overall health information–seeking behavior and reported that 74% of American adults use the internet. they have commonly ended as riders to benefit sets. or. and thus known amount of money. The challenge in practice has been that information and retail decision-making tools have lagged in development. and. consumer awareness of this need can at least be appreciated indirectly by the explosive growth in informationseeking behaviors on the internet. The Result If one goes by the marketing language. The reasons and implications are not clear. in an alternate scenario less expensive to the company. ie. the platform for HSAs for many of the larger banks and plans in the United States. and providers can perhaps be forgiven for thinking they were the permanent beneficiaries of a broadened awareness of their usefulness on the part of the American public.7 The US Government Accountability Office reported in 2006 that the average employer contribution was $1064. in many cases. 9. leading to what some have called the emerging retail health care marketplace. draining HSAs early and often. Rather. researchers found that. Canopy Financial. While difficult to quantify. 56% of American adults had sought information about a personal health concern from a source other than their doctor. it was $1600. Current economic troubles are accelerating this type of decision. with unspent balances frequently rolled over to retirement account contributions. employment health benefits are a more predictable. they are using budgets such as HSAs to pay for them. respectively. in 2007. 5 • Oct/Nov 2010 Bolles—Integrative Medicine in the Marketplace . New Rules for Employers Codified into these new products. The lack of engagement can perhaps be understood. from 16% in 2001 to 32% in 2007. In the early days of CDHP product use. Despite the use of what was presumed to be intrinsically appealing. 75% of those have searched for health information at least once. Consumers are beginning to have access to more information about the goods and services they consume from health care providers and plans. This is a huge advantage for employers who used to be forced to absorb these costs. Providers have historically felt captive to agreements of this type because of the ability of insurers to control the flow of patients.9 A New Relationship With Consumers Some implications for providers—and perhaps especially for nonconventional medical providers—may be coming into 22 Integrative Medicine • Vol.8 Why is this significant? With average balances greater than annual contributions. These changes were driven less by policy and more by political leverage—a force that is often migratory. for families. FSAs). creating a political opportunity. No one understands quite yet what this means. and 10% of internet users search daily for such content. Canopy further reported in January 2009 that individual and family HSA balances in the third quarter of 2008 had dropped by only 2% and 4%. Then things began to change. Unprepared Providers So where have providers been during these changes? Judging by the lack of visible professional and interprofessional dialogues on this subject. also called 125 Flexible Spending Plans. No. with tremendous uncertainty about what the final responsibility would be. covered services that are embedded into all health plan products. There is evidence that consumers started to resist spending money. and as yet really do not match in richness the profundity of change in benefit design. appearances suggest that they are unengaged and unprepared.6 The result of this trajectory is a profound change in the supply-demand dynamic. exhausting to maintain. consumers initially spent freely (for CAM services as well). additional buy-up expenses for employers who. but in reality a discounted health care service plan made possible by the ability of insurers to control access to certain providers who have agreed to contractually negotiated price discounts. consumers are not spending money on services that were previously being consumed. According to the Center for Studying Health System Change. reported in its fourth quarter 2008 report that the average HSA balance for individuals was $1429. The effects of this scenario are still playing out. now find themselves in such precarious financial positions that they are being forced to stop paying for such services. Those using the internet for this purpose had doubled in number in 6 years. In response to grass-roots and professional action. If and when employees’ health expenses exceed that amount. Eisenberg’s initial study data2 created something of a consolidation of public awareness on the use of CAM. they are on the hook for the substantial middle ground of health care costs.amount that can be added to by employees. these mandates have rarely become core benefits. What formerly was bonafide insurance has evolved into capped utilization models at prices that are often discounted to a point below providers’ ability to deliver the services. defined as satisfaction of consumption needs and desires. controlled. The Captive Provider From the providers’ standpoint. during the late 1990s and into the early 2000s health plans were forced to broaden coverage for CAM services. the advantage of CDHPs for employers (purchasers) is mainly that their exposure (costs) is capped because of the limits on first-dollar coverage (due to a benefit that is based on utilization management). and blunt in its application. Another version is health reimbursement accounts (HRAs. the goal behind this direction in new products seems to be conceptually sound: Make consumers more cost-conscious by putting them in a clearer position of buying health care. only employees make pretax contributions. which are also pretax contributions to accounts that employees can draw on to pay for certain Internal Revenue Service–approved health care expenses.
they are framing their decisions in very different terms— terms that parallel retail considerations. etc. 9. and. as well as some potentially painful disruption. however. Information management—perhaps the truest currency of health care in practice—is shifting substantially to include or focus on consumers. meaning that decisions about that spending will potentially be very different. there is little consumer overlap. access to electronic medical records is becoming a benchmark for hospitals and clinics. more clearly acknowledges that becoming a patient is really an agreement to a social contract that it may be important to explicitly acknowledge as a way of transitioning into someone’s care. health plans are developing customized health plan products aimed at more precise life-circumstance demographic segments such as young adults with very few health care needs. despite low national adoption figures. No. the slow broadening of product and a The Natural Marketing Institute. Consumers see purchases of services as a means to an end. socially-conscious. this emerging retail health care marketplace offers some compelling opportunities. to shop at both Wal-Mart and NeimanMarcus. we create trust with consumers. some shop at Target. what do they do? They compare prices and value. and providers can no longer assume a given patient is uninformed and compliant without some measure of autonomy in decision making.” b The taxonomy of patient vs consumer is important to consider because providers and patients often hold different assumptions about the terms. Consumers in many cases pay more for a sense of enhanced quality simply because it makes them feel good. The clinical equivalent of going above and beyond expectations in customer service is likely to come into play with uncertain consequences. and needs to be explored.a There are signs on the supply side that this new position for consumers is being recognized. A marketing message of information ownership is becoming evident across many of these efforts.com for 1 example). a price-point premium of 10% to 20% can be expected to be paid because of the intrinsic values of a product. The factors that influence these behaviors and decisions include price. for some 30 million or more Americans. Providers look for the quantitative changes in clinical findings. but rarely skip Target. earth-friendly. Commonly. older adults with Medicare gap coverage needs. and positioning all the time. or who bears the burden of a health challenge) forces a necessary focus of attention. Value is a complex calculus in consumers’ minds. and decisions about health care service consumption are beginning to reflect these as well. caring. access. particularly when they are outside health plan coverage. What will become visible in health care that influences With this fundamental reordering of the legacy health care marketplace and the demand side’s increasing influence on what the supply side offers up. but. integrative providers need to be aware of the perception of difference. To think of someone as a consumer is not necessarily to demean their suffering but. consumers will normally shop at an adjacent 2 of the 3. in a retail health care marketplace. products.com. messages. some consumers shop at Wal-Mart. If we can guide without selling. Many argue passionately that the term patient (someone who suffers. formed to examine the marketing segment known as LOHAS (Lifestyles of Health and Sustainability) identified that. What will be our clinical equivalent? Identify Your Customers and How You Position Your Services Retailers intentionally segment their markets. etc). social technologies employed to rate doctors and the quality of patients’ experiences are emerging on the internet (eg. If a consumer needs something that is available from several retail sources. spiritual. and the two have been woven into 1 product. are accustomed to making comparative price-point decisions. Consumers now are asking by their behaviors to unwind these 2 elements and to make decisions about services based on information digested before a health care service purchase is made. Experiments in price-point comparison and bundling of services into new consumer-facing products such as web portals that present costs of care and options are being conducted (see Carol. Patients are now consumers. Consumers look for value. Consumers will buy from retailers that meet their minimum expectations but will prefer to return to those that exceed these expectations. empathy. Additionally. etc. ie. Frequently. Whether consumers think of themselves in this light is not clear. what can or should we do? Consider Separating Information From Care Providers have historically been the source of both services and information. and some shop at Neiman-Marcus—3 retailers on a price-point continuum who have adopted very different brand management and pricing strategies. The quantitative changes produce the qualitative changes. For integrative health care providers. with uneven results. As well. perhaps. on the one who needs healing. Consumers are more often in a position of spending money that they see as their own instead of their health plans’. consumer-patients come into a doctor’s office with recent internet research in hand. HealthGrades. ratemds. and are finding that providers rarely think in similar terms. and how providers define that end will ultimately make a big difference to consumers. etc.focus. If what is required is to begin to think in new terms about all this. a concept that is challenging both the existing health care system and consumers: Managing personal health information is a locus of control that may someday redefine important aspects of health care. Bolles—Integrative Medicine in the Marketplace Integrative Medicine • Vol. “elevation by association. whereas retail consumers consistently look for qualitative changes in their lives. but at its heart is a very personal definition that factors quality in with quantity and price when decisions are made (along with additional factors such as time.com). discuss finds and deals with friends and family. is a victim. What Does All This Mean for Integrative Health Care Providers? service availability is beginning to resemble normal retail dynamics. Consumers do this both because of the perception of quality and because of a halo effect.b and while they seek services because of clinical needs or interests. but they also include perceptions of the quality of goods and experiences and how being associated with that retailer makes them feel. Personal health record products are emerging. for example. Think of Clinical Outcomes as Retail Outcomes Providers and consumers think in terms of outcomes but framed in different ways. For example. 5 • Oct/Nov 2010 23 . but these are usually independent of clinical outcomes and often evoke dismay and anger in the rated physicians because it is easy for a single disgruntled patient to hurt someone’s reputation by making unfounded charges or claims.
values. Those who do this are more likely to thrive in a retail health care marketplace than those who do not. those with hubris often are humbled as those with real power assert themselves. Expectations for a broadened paradigm of health and healing that focuses more on health promotion than disease management are high.how value is defined to consumers? As integrative health care providers find it necessary to appeal directly to consumers who make purchase decisions that are influenced by entirely new sets of considerations. Consumers don’t agree. more likely to thrive than those who do not. Shared responsibilities and collaboration in generating. it is very likely that tensions will arise when this is not viewed as a collaborative effort. as indicated in its origins in Greek mythology. 2009. adding to. they also want to know what happens when they don’t get what they expect. their services. The people we surround ourselves with and their healthy lifestyle practices are the greatest determinants of our own. By extension. Despite the best intent 24 Integrative Medicine • Vol. and preferences and to rethink how they present themselves. Retail products have service warranties. and acting on personal health information is likely to be the basis for a new social contract between providers and consumer-patients. in fact. documenting. how will providers and professions respond? Useful Prospective Concepts A set of prospective concepts may help set the stage for a more wide-ranging and organized discussion that will become more important as this retail health care marketplace takes shape. and as more tools come online where they can actively participate in reviewing. and controlling some aspects of this content. Healing may be the province of the individual. and why. receptivity. Rather. but health is a collective effort that is heavily dependent on the health of the community we live in. if data about information-withholding behaviors cited earlier are accurate. and. No. Concept 3: Providers Are Resources and Guides. and openness (see Concept 1). and perspectives. If we are to effectively engage people in their own health. see Schultz AM. It’s really an extension of the paternalistic and often condescending position providers have taken with patients over the years. and trade-offs. as patients return for more and more services in their own personal N-of-1 clinical trials.” Retail businesses orient their thinking toward the satisfaction of the consumer. Washington. as many have previously observed. Concept 1: The Consumer is King—and Queen This concept is not meant to assume that the consumer is automatically prepared to make critical decisions about care for themselves and their loved ones—far from it.” The other was a summary of consumer guidance that came from Diane Pampling: “Nothing about me without me. It will be interesting to watch what transpires in health care marketplace dynamics over the next several years. Chao SM. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. In the past. DC: National Academies Press. again. and the gestalt of the consumer-patient experience. agreeing on. Institute of Medicine. Health care reform efforts have created new opportunities for integrative providers to offer services and fulfill roles that have been largely unavailable until now. In a retail health care marketplace. These concepts are presented in a proposed ordinal ranking because they build on one another. but providers who think through how they will address unmet expectations are. they go away? Retailers track this all the time. Consumers are coming to see their personal health information as just that. needs. Concept 4: Value Matters—And It Must Be Communicated Consumers who are spending money on products and services want to know what they are getting for their money. how often are providers guilty of imposing their own agenda on them? Once they have choices. Conclusion c For more information on the summit. this lack of hubris can be as simple as just listening to consumer-patients from a perspective of humility. but it remains to be seen what this means in operation. need to begin to listen to consumers about their interests. priorities. Concept 5: It Takes a Village Health care is local. considerations. they’ve been rewarded for failure in many ways. Many consumers have effectively created their own integrative care teams—members of the team just don’t always know it. a consumer can’t return a failed or ineffective service. providers and other resources must figure out how to tell their messages of value that essentially promise something in return for what consumers spend. If we fail to understand that context. Consumer-patients come in with their own agenda. Providers who effectively engage consumers in a sense of shared ownership and responsible distribution of this information will tend to thrive in this marketplace more than those who do not. Not Gods Hubris has often been a characteristic of the position providers have adopted in relation to patients. we must present solutions that are seen as relevant within the context of their lives. like retailers. Consumers see their lives as ecosystems and make decisions about what they do and how they do it in the context of an often complex set of dynamics. 9. will consumers tolerate this behavior? Will we even know when. For providers. In the retail health care marketplace. Two important representations of this mindset were presented at the Institute of Medicine’s Summit on Integrative Medicine and the Health of the Public in 2009. What will be the corollary in health care delivery? Concept 2: Information Ownership Resides With the Consumer Providers and vertically-integrated systems are used to a mindset that ownership of clinical information is their exclusive province. we are likely to be replaced by someone who does. 5 • Oct/Nov 2010 Bolles—Integrative Medicine in the Marketplace . McGinnis JM. providers have been spared the consequence of having financial exposure to failed clinical outcomes.c One was a quote from Art Berarducci: “Every patient is the only patient. it is meant to suggest that providers.
Cohen GR. 2010. Available at: http://www. The economic survivors of this transition—and the reasons for their survival—may more profoundly change health care than any other dynamic. because of our historically strong relationships with consumers. Norlock FE. a significant gap between policy making and the marketplace may still exist. CELESTIAL ARTS/TEN SPEED PRESS Distributed by Bolles—Integrative Medicine in the Marketplace Integrative Medicine • Vol. et al. 3.pdf. No authors listed. GAO 06 798. Internet activities. Minnesota. Kessler RC. Calkins DR. February 27. and now as a consultant and entrepreneur.com/article/pressRelease/idUS135540+26-Jan2009+MW20090126. 2010. Available at: www.items/d06798. a vice president for Institutional Advancement at Northwestern Health Sciences University in Bloomington. a consumer product developer and manager for UnitedHealth Group. SAY GOODBYE TO THOSE UNWANTED POUNDS! In this complete revision of the Alternative Medicine Deﬁnitive Guide best seller.135(4):262-268. at-home exercises and much. 7. Accessed August 20. much more! To order this and other great health books. linking vision and infrastructure. Unconventional medicine in the United States.crnstone. 9. 2010.nih.jpg. Ellen Kamhi provides a complete. Committee on Finance. the fundamental dynamic between provider and patient has shifted. then as a nonprofit institutional executive. Available at: http://www.pdf. Track Rep. 6. Pew Internet. Foster DF. The speed of change is placing great pressure on all providers to prepare to respond with foresight. and a reshaping of their own sense of place than has ever been required. Senate: Consumer-Directed Health Plans.pdf. A HOLISTIC WAY TO LOSE WEIGHT AND KEEP IT OFF. Bronner K. January 26. Prevalence. 2009. Foster C. Individuals who focus on entrepreneurial efforts may be more significantly rewarded than those who expect systemic change to provide greater assurance of economic viability. Accessed August 20.95 plus shipping and handling ONLY 1. New concepts in weight management–inlcuding metabolic syndrome. No. 5 • Oct/Nov 2010 25 . are positioned well to benefit from these evolving dynamics—if we pay attention. according to Canopy’s Q3. Kessler RC. Report to the Ranking Minority Member.and concentrated efforts. Goodman D. 5.org/downloads/ reports/Spending_Brief_022709. has been in health care for more than 25 years. Stephen Bolles. No matter what form the new health care legislation finally produces. Accessed August 20.com/ newsletters/HSA%20Market%20Report%20Q4-canopy08. achieveable weight-loss and weightmanagement program.dartmouthatlas. Older Americans not discussing complementary and alternative medicine use with doctors. visit naturalsolutionsmag. Skinner J. Average health savings account balances show modest declines in wake of U.S.reuters. DC. 2. Available at: www. 2010. Available at: http://nccam. first as a provider. and patterns of use. 9. Fisher El. insulin resistance and the role of hormones such as ghrelin– are supported with the latest scientiﬁc studies. Davis RB. Available at: http://www. 2008 Aug. Accessed August 4. References F INALLY. and Outcomes: More Isn’t Always Better. Health Care Spending. $18.. 8.gov/news/2007/011807. No authors listed. Ann Intern Med.gao. business nimbleness. Accessed August 20.pewinternet. tasty recipes and an eating plan. financial crisis.328(4):246-452. Eisenberg DM. August 2006. HSA Market Report Q4-2008. 1993. costs. Reuters. Early Enrollee Experiences with Health Savings Accounts and Eligible Health Plans. No authors listed. Delbanco TL. Quality. 2009. Dr.S. 2001. 4. Also includes new ideas for overcoming diet challenges..(20):1-8. 2010. Integrative health care practitioners. National Center for Complementary and Alternative Medicine. United States Government Accountability Office.htm.org/Static-Pages/Data-Tools/Download-Data/~/media/Infographics/ Trend%20Data/January%202009%20updates/Internet%20Activities%20-%20all%20 -%201%206%2009.gov/new. Tu HT.com/go/shop or call 800-841-2665 or visit your local bookseller. N Engl J Med. Accessed August 4. and developing strategies to encourage and facilitate effective and humanistic corporate community and cultural integration. Long-term trends in the use of complementary and alternative medical therapies in the United States. U. His work focuses on strategic effectiveness. 2010. No authors listed. Dartmouth Institute for Health Policy and Clinical Practice. Striking jump in consumers seeking health care information.
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