Health Care Reform Memo: October 1, 2012
Deloitte Center for Health Solutions publication
The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.
My take: why engaged consumers are critical for the future of health care
From Paul Keckley, Executive Director, Deloitte Center for Health Solutions
I just finished the final accounting for my knee episode last November and subsequent blood clot. The scorecard: total charges billed by doctors, hospitals, labs, pharmacies, and over-the-counter “stuff” including bandages, etc.: $23,786. Of this, I paid $1,975 out-of-pocket. Pretty good deal! I was a guest in four hospital emergency rooms, including three to aspirate my knee so I could walk, and used 12 different labs in seven states for blood testing to monitor my warfarin dosage. I saw my primary care physician and surgeon twice, gratefully engaging with both via e-mail regularly through the process.
It took a while to figure this out, and along the way I learned a lot about the health care system:
- It’s hard to know how much anything costs. Prices are not readily available, and often they bear no resemblance to what things cost or what’s actually paid by the insurance company. Getting answers about costs is tough, too. Front desk folks seem put-off if queried about costs, though quite effective in collecting insurance information and co-payments up front.
- The insurance company’s “explanation of benefits” sometimes bears resemblance to what’s paid out-of-pocket, but not always.
- Getting anything scheduled or a question answered by telephone requires a ten minute wait to get to a living, breathing person. And for a physician’s office, unless it’s an emergency, forget about it.
- The system is archaic when it comes to information management: I filled out countless forms that repeatedly asked the same questions, sometimes for the same organization that did not have the capacity to share information across its multiple sites.
But thankfully, all the “piece work” for me came together for a successful outcome: I am walking without pain, except when going down stairs, jogging more frequently, and off medication.
Since 2008, the Deloitte Center for Health Solutions has surveyed consumers in the U.S. and other countries to assess their views about their own health and how they navigate their systems of care. We use a sophisticated multivariate methodology to determine differences between folks. Individuals navigate the system in several different ways—what patterns of behaviors and attitudes portray consumers’ unique views of the health care market? The result was a behavioral and attitudinal segmentation scheme we’ve monitored since. Our 2012 segmentation results will be released shortly.
In the U.S. market, we identified six segments: “content and compliant,” “sick and savvy,” “casual and cautious,” “online and onboard,” “shop and save,” and “out and about.” The “content and compliant” and “sick and savvy” tend to behave like “patients,” not particularly inclined to challenge a professional’s recommendation and query clinicians. The “casual and cautious” are simply not engaged because they don’t see the need. The other three segments show characteristics of activism, certainly disruptive to a system more comfortable with patients than consumers. “Out and about” actively seek and use alternative, non-Western medicine, often without the knowledge of their clinicians; “online and onboard” use online tools and mobile applications to assess providers and compare treatment options and provider competence; and “shop and save” is simply the value purchaser and is not content with paying more than necessary under any non-emergency scenario.
2012 health care consumer segments:
Source : Deloitte Center for Health Solutions, “2012 Health Care Consumer Segments,” October 2012
Amazingly, the composition of the U.S. consumer market has changed little across the half decade that endured the second longest economic downturn in our history and an unprecedented spotlight on the health care system via the Affordable Care Act (ACA). I am struck by the 11% increase in the “casual and cautious”—perhaps health care is “fait accompli” and beyond their control to change their plight or its trajectory. And the “shop and save”: 4 percent who, then and now, comprise the cost-conscious, price-driven element of the market. Go figure. Virtually every other industry in our economy has seen an uptick in price sensitivity and value purchasing—cars, housing, furniture and clothing. Store brands have gained market share vs. national brands, discount retailing has increased dramatically, and the same is true in other industries as well. In most sectors, “premium brands” have been resilient for the upscale cohort but increased price sensitivity has driven more purchasers to seek better deals.
It’s easy to see why “shop and save” is such a small and seemingly stagnant segment. The fact is it’s hard to be a “value shopper” in health care when all this “stuff” is so confusing and outsiders have limited access to what things cost or how much they’ll spend. The market is deluged with “Top 100” lists intended to help consumers cut through the noise, but with 700 “Top 100” hospitals, which list matters most? And every airline magazine now features “top doctors” along with steakhouses to shortcut our shopping. But costs and pricing are rarely provided.
Having gone through this knee ordeal, I have concluded the health system operates as if we’re not consumers. We are “patients” to our hospitals, doctors think us incapable of managing health on our own or are too lazy to engage, and drug manufacturers depend on prescribers to sell their products. And we are “members” to health plans and employers who choose insurance options for us and then monitor our use. It’s easier for providers to manage patients than engage consumers; it’s a completely different business for health insurers to plan to sell to individual consumers vs. employers and government contractors.
In my view, the most significant trend in the U.S. system not fully understood nor embraced by its stakeholders is the impact of engaged consumers. Engaged consumers will test our value propositions, require information technologies that eliminate redundant testing and paperwork, and demand information about the evidence supporting a treatment recommendation and its associated costs before the “transaction” is finished. This will accelerate as employers embrace defined contributions in lieu of defined benefits and state health insurance exchanges (HIXs) create a new market for individuals to purchase coverage.
Millennials (18-29 years olds) are there now; the younger Generation X (40-45 years olds) is just behind. It’s not a matter of if, but how soon. And for them, it can’t come soon enough.
I am thankful to have survived my knee episode without further complication, but it could have been much easier and perhaps less costly—it’s hard to know. The secrets of the system’s costs are still perhaps its most guarded.
Paul Keckley, Ph.D., Executive Director, Deloitte Center for Health Solutions
PS – This Wednesday, the first of three Presidential debates will be aired at 9pm EDT from Denver with PBS’ Jim Lehrer moderating. Health care is slated as one of the six topics for the domestic issue focused agenda.
HHS provides funding for mental health workforce expansion targeting at-risk populations
Last week, the U.S. Department of Health and Human Services (HHS) announced $9.8 million in funding for 24 graduate schools that offer social work and psychology degrees. The three-year grants are intended to increase the mental health workforce to provide services for at-risk individuals, including veterans and individuals with mental illnesses living in rural areas.
Background: Section 5306 of ACA allocates funding for mental and behavioral health education and training grants for higher education institutions.
CMS: new initiative to study avoidable hospitalizations for nursing home residents
Last week, the Centers for Medicare and Medicaid Services (CMS) introduced the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents program partnering with seven organizations and 145 nursing facilities to study avoidable hospitalizations for seniors living in nursing homes.
Background: Section 3201 of the ACA established the Center for Medicare and Medicaid Innovation to implement innovative payment systems to improve quality of care and reduce costs for plan participants and beneficiaries. Section 2602 of the ACA established the Medicare-Medicaid Coordination Office to improve coverage and payment coordination for dual eligibles.
Health insurance exchange update: guidance for multi-state plans
The U.S. Office of Personnel Management (OPM) released the draft 2014 Multi-State Plan Program (MSPP) application for interested health insurance issuers this month. Per ACA Section 10104, the OPM must contract with at least two multi-state plans (MSPs) that offer coverage through HIXs in all geographic regions. The OPM proposes the following:
- MSP issuers may phase in over four years. In the first year of the MSPP contract, MSPs must be offered in 60 percent of states and 85 percent in the third year
- MSPs would be able to participate in part rather than all of the states initially
- OPM may enter into contract negotiations with any applicant who submits a complete, responsive application that demonstrates to OPM’s satisfaction that the applicant is able and willing to meet the requirements to become an MSPP issuer
- MSPP issuers must accept enrollments beginning October 1, 2013 for coverage beginning as early as January 1, 2014
(Source: OPM, “2014 Multi-State Plan Program Application DRAFT,” September 2012)
Comments will be accepted through October 22, 2012.
Report: safety net providers critical for ACA’s insurance coverage provisions
Last week, the National Academy of State Health Policy released a report about the role safety net providers could play relative to the insurance coverage expansion provisions in the ACA. The report highlighted areas where safety net provider involvement is critical:
- Conducting outreach to uninsured or under-insured clients to help determine eligibility for a state’s HIX or Medicaid program
- Assisting individuals with enrollment, as many safety net providers already have services in place
- Safety net providers participating in Qualified Health Plans (QHPs) in a HIX can help promote continuous insurance coverage for low-income individuals at-risk of churning between Medicaid and the HIX
Background: Section 1311 of the ACA requires that QHPs include “essential community providers, where available, that serve predominantly low-income, medically underserved individuals.” Also, per Section 2201 of the ACA, states must coordinate enrollment efforts between the state’s HIX and Medicaid program. According to guidance from HHS, the U.S. Supreme Court’s June 2012 ruling allowing states to reject Medicaid expansion does not exempt states from Section 2201 of the ACA.
Hospitals submit comments on IRS charitable hospital rule
Last week, the American Hospital Association (AHA) and the Catholic Health Association (CHA) submitted comments to the U.S. Internal Revenue Service (IRS) about its Additional Requirements for Charitable Hospitals proposed rule released in June 2012. Among others, their recommendations include:
- The effective date for final regulations be postponed to after January 1, 2014
- The IRS allow hospitals to individually decide the most effective and efficient way to meet financial assistance policy (FAP) requirements with full disclosure rather than the adoption of the proposed uniform procedures
- The U.S. Department of the Treasury establish an “intermediate sanctions” period to allow hospitals with infractions to resolve them without losing tax exemption status
- The IRS provide clarification that other procedures for publicizing FAP will be allowed to ensure hospitals use the most effective way to inform their community
- The removal of additional requirements for emergency medical care that go beyond the scope of Emergency Medical Treatment and Labor Act (EMTALA) requirements
- Issuing clarification to allow hospitals to continue to include insured patients who struggle to pay deductibles and co-pays in their FAP, and limit the notice and application period for financial assistance to no more than 180 days total
Background: per ACA Section 9007, IRS code was amended to include new requirements hospitals must satisfy to maintain charitable organization status including: the information that must be included in its FAP and emergency medical care policy, methods to widely publicize its FAP, maximum amounts FAP-eligible individuals may be charged for emergency care. The rule also describes hospital collections practices that are permitted and prohibited in charitable hospitals, and all requirements would apply to taxable years beginning after March 23, 2012.
House bill proposes CBO expand projections for prevention and wellness programs
Before Congress went on its pre-election recess, Representative Michael Burgess (R-TX), with 16 co-sponsors, introduced the Preventive Health Savings Act (H.R. 6482), which would require the U.S. Congressional Budget Office (CBO) to look beyond the typical 10-year forecasting period when determining cost savings related to disease prevention and wellness programs. The bill was referred to the House Committee on the Budget on September 21, 2012.
FDA receives approval from Congress to collect funding from the generic drug industry
Before leaving for pre-election recess, Congress authorized the U.S. Food and Drug Administration’s (FDA) collection of fees from the generic drug industry per the Generic Drug User Fee Amendments (GDUFA) of 2012, which is part of the FDA Safety and Innovation Act. GDUFA was passed in July of this year to increase availability of generic drugs on the market and would allow the FDA to receive funding from the generic drug industry to help expedite reviews of generic drug applications. The FDA has been unable to review generic drug applications in a timely manner due to the high volume of applications and its limited resources. According to the FDA, there are 2,500 applications for new generic drugs waiting for FDA approval. The FDA is scheduled to begin the program today.
Health insurance exchange update
Thursday, HHS announced that Arkansas, Colorado, Kentucky, Massachusetts, Minnesota, and the District of Columbia (D.C.) were awarded grants to establish their HIXs. To date, a total of 49 states, D.C., and four territories have received HIX planning grants, and 34 states and D.C. have received HIX establishment grants. South Dakota Governor Dennis Daugaard (R) announced Wednesday the state will not set up its own HIX, and will allow the federal government to establish a Federally-Facilitated Exchange (FFE).
Senator Orrin Hatch (R-UT) sent a letter to HHS expressing concern over the “lack of transparency” from the agency with regard to the implementation of the FFE. The Senator remarked that with the November 16, 2012 exchange blueprint deadline quickly approaching, states have yet to receive adequate information on how the FFE will operate with state insurance law or cost estimates associated with selecting the FFE. Senator Hatch requests a response to his inquiries from HHS by October 19, 2012.
Related: Friday, Representative Fred Upton (R-MI) and Senator Chuck Grassley (R-IA) sent a letter to Secretary of HHS, Kathleen Sebelius, asking how HHS is tracking state spending of federal funds disbursed to states for HIX implementation. The letter also asks HHS whether effectiveness of grant use is being measured and whether HHS is providing guidance to states on how to avoid fraud, waste, and abuse.
Background: per Section 1311 of the ACA, a state can choose to establish a state-operated HIX, participate in a State Partnership Exchange (SPE), or allow the federal government to run an FFE in the state. States seeking to operate a state-based exchange or participate in a SPE must submit a blueprint of its plan and operational capabilities by November 16, 2012. States choosing to implement a HIX through the federal partnership with HHS will be responsible for day-to-day management of plans and/or any consumer assistance functions, but HHS will be the authority over the FFE selecting state partners through which plan management and consumer assistance functions will be provided (i.e., infrastructure and operational partnerships).
- Last week, Insurance Commissioner Michael Consedine of Pennsylvania sent a letter to HHS Secretary Kathleen Sebelius seeking clarity on whether today’s deadline for the essential health benefit (EHB) benchmark plan is a hard or soft deadline. “HHS recently has directed states that they must identify their EHB benchmark by September 30th. Some communications from your agency indicate that this is a suggested response date while other indicates that it is a deadline of some sort. We again are asking for clarity on the process and timing for decision making at both the state and federal levels.” (Source: Insurance Commissioner Michael Consedine, letter to HHS Secretary Kathleen Sebelius, September 23, 2012)
Background: per section 1302 of the ACA, states must define an EHB benchmark plan that includes all ten statutorily required benefit categories. Each state must model its plan after one of the following health insurance plans: one of the three largest small group plans in the state by enrollment, one of the three largest state employee health plans by enrollment, one of the three largest federal employee health plan options by enrollment, or the largest HMO plan offered in the state’s commercial market by enrollment. According to HHS, states that do not define an EHB benchmark plan must use the small group plan with the largest enrollment in the state.
- Governor Jerry Brown (D) recently signed the California Birth Control Bill, authorizing registered nurses in primary care clinics to dispense specified birth control drugs or devices with an order issued by a physician, surgeon, certified nurse-midwife, nurse practitioner, or physician assistant. The bill prohibits clinics from employing nurses solely to perform drug dispensing duties. It also establishes standardized procedure including training requirements regarding educating patients on medical standards for ongoing women’s preventive health, and the extent of physician and surgeon supervision required.
- Nebraska issued a request for proposal for bidders to provide a Web portal to support the state’s HIX, administered by the Department of Insurance. The state has yet to adopt legislation or an executive order creating an HIX, but has received almost $6.5 million from HHS in HIX planning and establishment grants.
- A recent study of Arizona’s Medicaid program expansion found that the state would receive close to $8 billion in federal funding, insure an additional 435,000 residents, and create 21,000 jobs by 2017 with a $1.5 billion investment over the first four years if it elects to expand its Medicaid eligibility to 133 percent federal poverty level (FPL). Researchers also found that complying with ACA expansion to 133 percent FPL would save the state $1.2 billion when compared to complying with the “Healthy Arizona” proposition, which would expand eligibility to 100 percent FPL and offer more coverage to children.
mHealth task force releases recommendations for expanded use of mobile health
Last week, the mHealth Task Force met with Federal Communications Commission (FCC) Chairman Julius Genachowski to discuss its recommendations for successful adoption of wireless health technologies. The goal of the task force is to guide the FCC and other agencies in making wireless electronic health solutions routinely available as part of best practices for medical care by 2017. Highlights:
|Task Force Goals||Recommendations of the Task Force|
|1. FCC should continue to play a leadership role in advancing mobile health adoption||
|2. Federal agencies should increase collaboration to promote innovation, protect patient safety, and avoid regulatory duplication||
|3.The FCC should build on existing programs and link programs when possible in order to expand broadband access for health care||
|4. The FCC should continue efforts to increase capacity, reliability, interoperability, and radio frequency (RF) safety of mHealth technologies||
|5. Industry should support continued investment, innovation, and job creation in the growing mobile health sector||
Source: mHealth Task Force, “Findings and Recommendations: improving care delivery through enhanced communications among providers, patients, and payers,” September 2012
HHS, DOJ warn about fraud in hospitals
Last week, HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder issued a letter to five major hospital associations, calling attention to the use of electronic systems to duplicate records for the sole purpose of increasing payments. The letter warned that early reports have indicated that providers may be committing fraud by “upcoding” the severity of patients’ conditions for their own profit. CMS is currently reviewing billing through audits, and will use new tools authorized by the ACA to cease Medicare payments for those suspected of fraud.
Response: the AHA quickly issued a response noting that on 11 occasions they have requested CMS develop national guidelines for the reporting of hospital emergency department (ED) and clinic visits since 2001. Despite these requests, CMS continues to propose that, until national guidelines are established, hospitals should continue to report visits according to their own internal hospital guidelines to determine the different levels of clinic and ED visits. The letter also expressed hospitals’ concerns that without standardized guidelines new auditing programs are causing redundant audits, unmanageable medical record requests, and inappropriate payment denials that require time to appeal. AHA offered to assist CMS in the development of such guidelines and recommends that investments are made in provider education and payment system fixes to prevent payment mistakes.
Background: according to a recent New York Times analysis, hospitals have changed the Medicare billing codes they are using and have received $1 billion more in reimbursements in 2010 than in 2006 as a result. Hospital emergency rooms increased use of the two highest-paying reimbursement categories in 2010: 54 percent vs. 40 percent in 2006. (Source: Reed Abelson, New York Times “Medicare Bills Rise as Records Turn Electronic,” September 21, 2012)
My take: historically, when information systems are implemented in medical practices and hospitals, coding accuracy is increased. Hospitals are understandably frustrated by the warning and anticipate intensified anti-fraud efforts by government overseers.
Military leaders say junk food is a threat to national preparedness
Childhood obesity and junk food in schools poses a threat to national security, according to a report by retired military leaders released last Tuesday. The report highlights that one in four young adults are currently too overweight to join the military, and being overweight or obese is the number one medical reason adults are unable enlist. The study suggests that schools are a major contributor to the problem by offering poor food choices and lack of education about proper nutrition. Other notable findings include:
- U.S. Department of Defense spends an estimated $1 billion per year for medical care associated with weight-related health problems
- TRICARE—the military health insurance system serving active duty personnel, their dependents, and veterans—spends over $1 billion a year treating weight-related diseases including diabetes and heart disease
- Overweight recruits were 47 percent more likely to experience a musculoskeletal injury (i.e. sprain or stress fracture)
- More overweight recruits had to recycle back through boot camp
(Source: Mission Readiness: Military Leaders for Kids, “Still Too Fat to Fight”, September 2012)
My take: many schools are trying to improve cafeteria offerings and increase educational activities about nutrition; but demand from students for “junk” food and sugar-loaded beverages is problematic, as is parental involvement, food choices at home, and adequate exercise. Tackling obesity seems a matter of national urgency requiring an all-out war on its causes. It’s not just schools.
“We have to remember that 30 percent of our health care dollars are wasted according to recent studies. And that’s about $750 billion dollars. Fraud, waste, and abuse represents a small part of that, but in order to really make some headway on everything from inefficient care to improper diagnoses and lack of coordinated care, we have to have electronic medical records as a foundation to move that forward.”
—Harry Greenspun, M.D., Senior Advisor, Deloitte Center for Health Solutions, Fox Business, “Electronic Medical Records Causing Rise in Medicare Spending?” September 24, 2012
“Big employers are planning a radical change in the way they provide health benefits to their workers, giving employees a fixed sum of money and allowing them to choose their medical coverage and insurer from an online marketplace….The approach will be closely watched by firms around the US. If it eventually takes hold widely, it might parallel the transition from company provided pensions to 401(k) retirement savings plans controlled by workers and funded partly by employer contributions.”
—Anna Wilde Matthews, Wall Street Journal, “Big Firms Overhaul Health Coverage,” September 27, 2012
“Nearly 40 percent of consumers surveyed last year said they use hospital ratings to choose a health care facility, but there’s little agreement among the lists, raising questions about their value…At least 15 different groups rank health care organizations, but no two judge them the same way, which leads to widely divergent results.”
—Joyce O Donnell, USA Today, “A Health Disagreement: Which Hospitals are best? Even the experts can’t agree,” September 28, 2012
- Life expectancy: 78 years in U.S.; 75.5 years for men and 80.5 years for women. The U.S. ranks 41st in the world in life expectancy for women vs. 14th in 1985. (Source: U.S. Census Bureau and New York Times, “Life Spans Shrink for Least-Educated Whites in the U.S.,” September 20, 2012)
- Health care investments: in 2011, investments in health care increased to $368 million, up from $261 million in 2010. (Source: National Venture Capital Association)
- Medicare costs: 3.25 percent of gross domestic product (GDP) and forecasted to be 4.25 percent in 2030 if left as is; both Representative Paul Ryan (R-WI) and President Obama would lock in Medicare at GDP plus .5 percent. (Source: CBO)
- Organ donation: one of five donated kidneys is thrown away; over 115,000 on donor wait list; country divided in 50 donor districts; in 2011, 2,644 of 14,784 discarded—500 because a recipient could not be found. (Source: United Network for Organ Sharing)
- Employer sponsored health insurance: 9 percent of companies representing 2.58 million workers (3 percent of the workforce) anticipate dropping coverage in the next one to three years. (Source: Deloitte Center for Health Solution, 2012 Employer Survey, 2012)
- Illicit drug use: among youth age 12 to 17, 2.8 percent reported current non-medical use of prescription-type drugs in 2011—down from 4 percent in 2002. The rate of non-medical pain reliever use also declined during this period from 3.2 percent to 2.3 percent in 2011. Fifty-four percent obtained the pain relievers from a friend or relative or free, and 12 percent purchased them from a friend of relative. Among young adults aged 18 to 25, the rate of current nonmedical use of prescription drugs in 2011 was 5 percent. (Source: HHS, 2011 National Survey on Drug Use and Health, September 2012)
- Consumer spending: consumers increased their annual spending 3.3 percent last year, the fastest growth rate since 2006. The average level of spending in 2011, $49,705 —highest since 2008. Consumer prices rose 3.2 percent last year, offering one potential explanation for increased spending. (Source: Wall Street Journal, “Consumers Back to Feeling Flush,” September 2012)
- Total knee arthroplasty (TKA) volume increase: the number of annual primary TKAs increased 161.5 percent between 1991 and 2010 (93,230 to 243,802) while per capita utilization increased 99.2 percent (from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010). (Source: JAMA, “Total Knee Arthroplasty Volume, Utilization, and Outcomes Among Medicare Beneficiaries, 1991-2010,” September 2012)
- Variation in episode costs: episode costs for major medical procedures vary about 2.5-fold, and up to 15 for common chronic conditions. Costs were on average 14 percent lower among physicians who met certain quality and efficiency benchmarks. “This suggests a potential opportunity exists to improve the current efficiency of care across the health care system.” (Source: Health Affairs, “Wide Variation In Episode Costs Within A Commercially Insured Population Highlights Potential To Improve The Efficiency Of Care,” September 2012)
- Americans’ opinions of the ACA: 88 percent of Americans believe the ACA will be implemented in full/part either with minor changes (41 percent), major changes (31 percent), or as passed (11 percent). Twelve percent of respondents anticipate the ACA to be repealed completely. (Source: Associated Press, “AP-GfK Poll: Health Care Reform,” September 2012)
- Election issues: top issues in Presidential campaign: the economy (49 percent), federal budget deficit (41 percent), Medicare (36 percent). Among seniors, Medicare was more important, with 46 percent indicating Medicare is extremely important to their vote compared with 51 percent saying the economy is extremely important. Democrats (48 percent) are much more likely than Republicans (28 percent) to say Medicare is an extremely important factor in their presidential pick. Seniors (64 percent) and Democrats (62 percent) heavily favor keeping Medicare as it is today while many Republicans (48 percent) and voters ages 18-54 (44 percent) support switching to a fixed-value voucher program. (Source: Kaiser Family Foundation, “Kaiser Health Tracking Poll,” September 2012)
- Poverty rates: in 2011, the U.S. poverty rate was 15 percent, which represents 46.2 million people. (Source: U.S. Census Bureau)
- Medicare fix: 50 percent think Obama will fix Medicare vs. 44 percent Romney. (Source: Gallup/USA Today Poll of 1096 registered voters September 11-17, 2012)
- Excessive alcohol consumption: 14 drinks per week for men, or no more than four per day; seven per week for women, or no more than three per day. (Source: National Institute on Alcohol Abuse and Alcoholism)
National health reform: What now?
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