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Pathologists Bill Out-of-Network More Frequently than Other Specialties, According to Health Care Cost Institute Study

Two national studies find pathologists bill out-of-network more frequently than other hospital-based specialties, and one study links that behavior to insurer reimbursement rates

Surprise bills for out-of-network services continue to be an important issue for healthcare consumers. Now comes a recently-released report from the Health Care Cost Institute (HCCI) claiming that pathologists are the specialists that most often bill for out-of-network hospital charges.  

The HCCI study examined the prevalence and frequency of out-of-network billing among six specialties. The sample used for the report included 13.8 million healthcare visits to over 35 thousand hospital-based healthcare providers that occurred in 2017. The types of visits examined for the report were:

  • emergency medicine,
  • pathology,
  • radiology,
  • anesthesiology,
  • behavioral health, and
  • cardiovascular services.

The researchers calculated the percentage of out-of-network claims for both inpatient and outpatient visits to each type of the six specialties.

The study found that, overall, less than half of the specialties billed out-of-network for services obtained at in-network facilities. Providers with at least one out-of-network claim associated with an in-network outpatient visit ranged from 15% for behavioral health to 49% for emergency medicine.

Pathologists’ Out-of-Network Billing

Among the pathologists surveyed, HCCI found 33% had at least one out-of-network claim for an in-network outpatient visit. Providers with at least one out-of-network claim associated with an in-network inpatient visit ranged from 18% for cardiovascular services to 44% for both emergency and pathology services.

HCCI researchers also examined how often individual providers in the six specialties billed out-of-network at least one time and found that the majority billed out of network less than 10% of the time. However, this varied among the specialties with 36% of pathologists who billed out-of-network for inpatient visits, and 20% of pathologists who billed out-of-network for outpatient visits, did so more than 90% of the time.

The graphic  from the latest HCCI report, shows the share of providers who billed out-of-network at least once for inpatient and outpatient visits
The graphic above, taken from the latest HCCI report, shows “the share of providers who billed out-of-network at least once for inpatient and outpatient visits” and illustrates the percentage of out-of-network billings by pathologists compared to other hospital-based healthcare specialties. (Graphic copyright: Health Care Cost Institute.)

Pathologists Top List of Out-of-Network Specialists in Previous HCCI report

Last November, HCCI released a similar report that examined the commonality of out-of-network billing for the same six specialties plus surgical services that took place in 2017. Based on their collected data, they also estimated the amount of surprise bills that patients could expect to receive for those services.

That report found that nationally:

  • 16.5% of visits with emergency room services had an out-of-network claim from an emergency medicine specialist.
  • 12.9% of visits with lab/pathology services had an out-of-network claim from a pathologist.
  • 8.3% of visits with anesthesiology services had an out-of-network claim from an anesthesiologist.
  • 6.7% of visits with behavioral health services had an out-of-network claim from a behavioral health provider.
  • 4.2% of visits with radiology services had an out-of-network claim from a radiologist.
  • 2.1% of visits with surgical services had an out-of-network claim from a surgeon.
  • 2.0% of visits with cardiovascular services had an out-of-network claim from a cardiovascular specialist.

Surgical Services the Most Expensive Out-of-Network Bill

This study also found broad variation in charges between types of services and healthcare settings. The researchers determined that the potential surprise bills for surgical visits due to out-of-network claims were of the greatest magnitude. HCCI estimated that the average potential surprise bill associated with an inpatient surgery was $22,248, while the potential surprise bill associated with an outpatient surgery was $8,493.

Out-of-Network Surprise Billing Varies Widely Depending on Location

The data was further broken down by state. For pathology services, the percentage of visits with out-of-network services in 2017 ranged from 0.3% in Minnesota to 75.3% in Kansas. HCCI researchers estimated the potential surprise bill for out-of-network pathology claims for inpatient services ranged from $14 in Louisiana to $167 in Delaware. The estimated surprise bill for out-of-network outpatient pathology services ranged from $23 in Louisiana to $218 in Wyoming.

Pathologists Also Top Out-of-Network Biller in Yale University Study

A Yale University study into surprise billing released in December and published in the journal Health Affairs found similar results, Modern Healthcare reported. This study examined surprise out-of-network bills incurred by patients who sought care at in-network hospitals for four types of specialists that are not chosen by patients:

  • pathologists,
  • anesthesiologists,
  • radiologists, and
  • assistant surgeons.
Zack Cooper, PhD
Zack Cooper, PhD (above), is an associate professor of public health at the Yale School of Public Health and one of the study’s authors. He noted in Yale News, “When physicians whom patients do not choose and cannot avoid bill out of network, it exposes people to unexpected and expensive medical bills and undercuts the functioning of US healthcare markets,” adding, “Moreover, the ability to bill out of network allows specialists to negotiate inflated in-network rates, which are passed on to consumers in the form of higher insurance premiums.”  (Photo copyright: Yale School of Public Health.)

For the Yale study, the researchers examined employer-sponsored insurance claims from a major commercial insurer for healthcare visits that occurred at in-network hospitals in 2015. They found that 12.3% of cases involving a pathologist were billed out-of-network, which was the highest percentage of the four specialties analyzed. By contrast, 11.8% of anesthesiologists, 11.3% of assistant surgeons, and 5.6% of radiologists billed out-of-network for their services.

The Yale study also found that “the ability of these four specialties to send patients out-of-network bills allowed them to negotiate high in-network payments from insurers, which leads to higher insurance premiums for individuals.”

The Yale study researchers determined that were these specialists unable to bill out-of-network, the particular healthcare plan would save 3.4% of their expenditures or about $40 billion per year, Modern Healthcare reported.

Surprise bills for out-of-network services burden both patients and providers. Insurers want beneficiaries to have access to hospitals and services, but providers in many specialties do not want to contract with those insurers due to low reimbursements.

This disconnect results in providers staying out-of-network and patients receiving surprise bills for out-of-network services even though the hospital was in-network. And pathologists are at the top of the list.

Anatomic pathologists across the country will want to track how government and private payers respond to these findings by amending coverage and reimbursement guidelines in ways that may be unfavorable to the pathology profession.

—JP Schlingman

Related Information:

Pathologists Most Frequent Surprise Billing Offenders, HCCI Finds

How Often Do Providers Bill Out of Network?

How Common is Out-of-Network Billing?

Out-of-Network Billing by Hospital-based Specialists Boosts Spending by $40 Billion

Study Exposes Surprise Billing by Hospital Physicians

Out-of-Network Billing and Negotiated Payments for Hospital-Based Physicians

Clinical Laboratories, Pathology Groups Being Squeezed by ‘Balanced Billing’ Dispute That Puts Providers, Hospitals, and Insurers at Odds

As Primary Care Providers and Health Insurers Embrace Telehealth, How Will Clinical Laboratories Provide Medical Lab Testing Services?

When patients use telehealth, how do they choose medical laboratories for lab test orders their virtual doctors have authorized?

Doctors On Demand is expanding the nation’s primary care services by launching a virtual care telehealth platform for health insurers and employers. This fits into a growing nationwide trend toward increased use of remote and virtual doctor’s visits. But how should clinical laboratories and anatomic pathology groups prepare for fulfilling virtual doctors’ lab test orders in ways consistent with current scope-of-practice laws?

The rise of virtual care is made possible by innovations in digital and telecommunication technology. Driven by studies showing more patients are opting out of conventional primary care visits that take too much time or are too far away, the healthcare industry is responding by bringing medical services—including pathology and clinical laboratory—closer to patients through retail settings and urgent care clinics.

Many pathologists and clinical laboratory managers are unaware of how swiftly patients are becoming comfortable with getting their primary care needs met by other types of caregivers, including virtually. Recently, the Health Care Cost Institute (HCCI) published data showing that visits to primary care physicians declined 18% from 2012 to 2016 among adults under 65 who had employer-sponsored insurance. However, during these same years, visits with nurse practitioners and physician’s assistants increased by 129%!

Another way that providers are making it easier for patients to access healthcare is through the Internet.

Doctor On Demand, a San Francisco-based virtual care provider, is targeting insurers and employers with its Synapse telehealth platform, which integrates into existing health plan networks and enables virtual primary care, according to a news release.

“Through our fully integrated technology platform, we’re putting the patient first and introducing continuity of care not previously available through virtual care solutions,” said Hill Ferguson, CEO of Doctor On Demand in a statement announcing the launch of Synapse on the Humana (NYSE:HUM) health plan network. (Photo copyright: The Business Journals.)

How Synapse Works

Humana is using Synapse in its new On Hand virtual primary care plan, the news release states. Humana said its members have no copay for the virtual doctor visits and $5 copays for standard medical laboratory tests and prescriptions. Synapse’s “smart referrals” function sends referrals to in-network clinical laboratories, imaging providers, and pharmacies, Healthcare Dive reported.

“Humana has a deep footprint, and this is a payer looking to create a virtual primary care network as a way to contain cost and thinking about how care is coordinated and delivered,” Josh Berlin, a Principal and Healthcare Co-Practice Leader with advisory firm Citrin Cooperman, told FierceHealthcare.

Changing Primary Care Relationships

Another insurer advancing telehealth is Oscar Health, which offers its own Doctor on Call telehealth platform. The New York City-based health plan reported in a year-end review that 82% of its members had set up a profile that gave them access to a concierge care team and 24/7 telemedicine services, including clinical laboratory test results. 

During 2018, Oscar’s concierge teams addressed 1.2 million questions from 77% of its members, the insurer said.

The graphic above, taken from research conducted by the Health Care Cost Institute (HCCI), shows that while virtual primary care has been expanding, conventional visits to primary care physicians fell 18% from 2012 to 2016 among adults under 65 who had employer-sponsored insurance. Simultaneously, visits with nurse practitioners and physician’s assistants increased by 129%! This indicates a shift in how patients view access to primary care physicians and may explain why telehealth is becoming an attractive option. How will clinical laboratories fit into this new healthcare paradigm? (Photo copyright: HCCI.)

Becker’s Hospital Review reports that telehealth usage by Oscar’s members is five times higher than the average for the healthcare industry.

Will Clinical Laboratories Receive Virtual Referrals?

In a way, it has never been easier for patients to see a primary care doctor or research symptoms. Additionally, the Internet makes it possible for patients to self-diagnose, though not always to the benefit of healthcare providers or the patients.

So, how should clinical laboratories respond to this growing expansion of virtual care doctors? Experts advise lab leaders to reach out to health plans soon and determine their inclusion in virtual healthcare networks. Labs also may benefit by making test scheduling and reporting accessible and convenient to insurance company members and consumers choosing telehealth.

During his keynote presentation at the 24th Annual Executive War College in May, Ted Schwab, a Los Angeles area Healthcare Strategist and Entrepreneur, said, “If you use Google in the United States to check symptoms, you’ll find 350 different electronic applications that will give you medical advice—meaning you’ll get a diagnosis over the Internet. These applications are winding their way somewhere through the regulatory process. (See Schwab’s expanded comments on this trend in, “Strategist Explains Key Trends in Healthcare’s Transformation,” The Dark Report, October 14, 2019.)

Schwab advises that in this “time of change” it’s critical for labs to take proactive measures. “What we know today is that providers—including clinical laboratories and pathology groups—who do nothing will get trampled. However, those providers that do something proactively will most likely be the winners as healthcare continues to transform.”

—Donna Marie Pocius

Related Information:

Doctor On Demand Launches Synapse, a New Virtual Care Platform Delivering Next Generation Primary Care for Health Plans and Employer Populations

Telemedicine Startup Doctor On Demand Taps Giant Health Partner to Debut Virtual Primary Care Plan

Doctor On Demand Rolls Out Virtual Care Platform for Primary Care

Humana and Doctor On Demand Launch Virtual Primary Care Plan to Bring More Services With Lower Costs to Patients, Insurers, and Employers

Trends in Primary Care Visits

Humana and Doctor On Demand Launch Virtual Primary Care Plan

Oscar Health’s Telemedicine Use Five Times Greater than Health Insurance Average

Strategist Explains Key Trends in Healthcare’s Transformation

25th Annual Executive War College Conference on Laboratory and Pathology Management

As the Public Becomes More Aware of the Large Variability in how Clinical Laboratories Price Their Tests, All Labs Need Strategy for Complying with CMS’ Pricing Transparency Requirements

Journalists, researchers, and a growing number of consumers now recognize the often huge variability in the prices different medical laboratories charge for the same lab tests

One step at a time, the Medicare program, private health insurers, and employers are putting policies in place that require providers—including clinical laboratories and pathology groups—to allow patients and consumers to see the prices they charge for their medical services. Recent studies into test price transparency in hospitals and health networks have garnered the attention of journalists, researchers, and patients. These groups are now aware of enormous variations in pricing among providers within the same regions and even within health networks.

There are several reasons that pricing is such a popular topic at the moment. Many medical laboratory professionals know, for example, how in January 2019 the Centers for Medicare and Medicaid Services (CMS) passed the IPPS/LTCH PPS final rule, which requires hospitals to post pricing information on their websites. Dark Daily covered this in “New CMS Final Rule Makes Clinical Laboratory Test/Procedure Pricing Listed on Hospital Chargemasters Available to Public.”

Now that hospitals’ medical laboratory test prices are required to be easily accessible to patients, researchers are beginning to compile test prices across different hospitals and in different states to document and publicize the wide variation in what different hospital labs charge for the same medical laboratory tests.

Journalists are jumping on the price transparency bandwagon too. That’s because readers show strong interest in stories that cover the extreme range of low to high prices providers will charge for the same lab test. This news coverage provides patients with a bit more clarity than hospitals and other providers might prefer.

Shocking Variations in Price of Healthcare Services, including Medical Laboratory Tests

The Health Care Cost Institute (HCCI) in conjunction with the Robert Wood Johnson Foundation (RWJF), examines price levels of various procedures and medical laboratory tests at healthcare institutions across the United States in the first release of a series called Healthy Marketplace Index. According to the HCCI website, “a common blood test in Beaumont, Texas ($443) costs nearly 25 times more than the same test in Toledo, Ohio ($18).”

In April, the New York Times (NYT) made the wide variation in how clinical laboratories price their tests the subject of an article titled, “They Want It to Be Secret: How a Common Blood Test Can Cost $11 or Almost $1,000.” The article discusses the HCCI findings.

The coverage by these two well-known entities is increasing the public’s awareness of the broad variations in pricing at clinical laboratories around the country.

Aside from the large differences in medical laboratory test prices in different regions, the HCCI found that there are sometimes huge price variations within a single metro area for the same lab tests. “In just one market—Tampa, Fla.—the most expensive blood test costs 40 times as much as the least expensive one,” the NYT notes.

In other industries, those kinds of price discrepancies are not common. The NYT made a comparatively outrageous example using ketchup, saying, “A bottle of Heinz ketchup in the most expensive store in a given market could cost six times as much as it would in the least expensive store,” adding, however, that most bottles of ketchup tend to cost about the same.

“It’s shocking. The variation in prices in healthcare is much greater than we see in other industries,” Amanda Starc, PhD, Associate Professor, Kellogg School of Management, Northwestern University, told the NYT.

The graphic above is taken from the New York Times article on test price discrepancies in healthcare. The range of prices for the medical lab test known as a comprehensive metabolic panel are for metropolitan areas only. The data is sourced from the Health Care Cost Institute study. It’s easy to see why patients would be confused by clinical laboratory pricing that varies so widely. (Graphic copyright. The New York Times.)

The CMS mandate designed to make the prices of medical services accessible to healthcare consumers has, in many ways, made things more confusing. For example, most hospitals simply made their chargemaster available to consumers. Chargemasters can be confusing, even to industry professionals, and are filled with codes that make no sense to the average consumer and patient.

“This policy is a tiny step forward but falls far short of what’s needed. The posted prices are fanciful, inflated, difficult to decode and inconsistent, so it’s hard to see how an average person would find them useful,” Jeanne Pinder, Founder and Chief Executive of Clear Health Costs, a consumer health research organization, told the NYT in an article on how hospitals are complying with the mandate to publish prices.

In addition to the pricing information being difficult for consumers to parse, it also may lead them to believe they would need to pay much more for a given procedure than they would actually be billed, resulting in patients opting to not get care they actually need.

Why Having a Strategy Is Critically Important for Clinical Laboratories

Clinical laboratories are in a particularly precarious position in all of this pricing confusion. For one thing, most hospital-based medical laboratories don’t have a way to communicate directly with consumers, so they don’t have a way to explain their pricing. Additionally, articles and studies such as those in the NYT and from the HCCI, which describe drastic price variations for the same tests, tend to cast clinical laboratories in a somewhat sinister light.

To prepare for this, medical laboratory personnel should be trained in how to address customer requests for pricing and how to explain variations in test prices among labs, before such requests become problematic. Lab staff should be able to explain how patients can find out the cost of a given test, and what choices they have regarding specific tests.

In 2016, Dark Daily’s sister-publication, The Dark Report (TDR), dedicated an entire issue to the impact of reference pricing on the clinical laboratory industry. In that issue, TDR reported on how American supermarket chain Safeway helped guide their employees to lower-priced clinical laboratories for lab tests, resulting in $2.7 million savings for the company in just 24 months. Safeway simply implemented reference pricing; the company analyzed lab test prices of 285 tests for all of the labs in its network, and then set the maximum amount it would pay for any given test at the 60th percentile.

If a Safeway employee selected a medical laboratory with prices less than the 60th percentile, the normal benefits and co-pays applied. But if a Safeway employee went to clinical laboratories that charged more than the 60th percentile level, they were required to pay both their deductible and the amount above Safeway’s maximum.

Safeway’s strategy revealed wide variation in testing prices, just as the HCCI report found. This means that employers can be added to the list of those who are paying much closer attention to medical laboratory test pricing than they have in the past. These are developments that should motivate forward-looking pathologists and clinical laboratory executives to act sooner rather than later to craft an effective strategy for responding to consumer and patient requests for lab test price transparency.

—Dava Stewart

Related Information:

Healthy Marketplace Index

Past the Price Index: Exploring Actual Prices Paid for Specific Services by Metro Area

They Want It to Be Secret: How a Common Blood Test Can Cost $11 or Almost $1,000

Hospitals Must Now Post Prices. But It May Take a Brain Surgeon to Decipher Them

New CMS Final Rule Makes Clinical Laboratory Test/Procedure Pricing Listed on Hospital Chargemasters Available to Public

Using the Reference Pricing Strategy, Safeway and its Employees Reduce Spending on Clinical Laboratory Tests by 32% in Only 24 Months by Selecting Lab with Lowest Prices

New AHA Report Finds Hospital Outpatient Revenue Nearing Inpatient Revenue, While CMS Proposes Paying Less for In-hospital Healthcare Services

Clinical laboratories that service both settings could be impacted as new CMS proposed rule attempts to align Medicare’s payment policies for outpatient and in-patient settings

Hospital outpatient revenue is catching up to inpatient revenue, according to data released from the American Hospital Association (AHA). This increase is part of a growing trend to reduce healthcare costs by treating patients outside of hospital settings. It’s a trend that is supported by the White House and Medicare and continues to impact clinical laboratories, which serve both hospital inpatient and outpatient customers.

The AHA published this study data in its annual Hospital Statistics, 2019 Edition. The data comes from a 2017 survey of 5,262 US hospitals. The report includes data about utilization, revenue, expenses, and other indicators for 2017, as well as historical data.

The AHA statistics on outpatient revenue suggest providers nationwide are working to keep people out of more expensive hospital settings. Hospitals, like medical laboratories, appear to be succeeding at developing outpatient and outreach services that generate needed operating revenue.

This aligns with Medicare’s push to make healthcare more accessible through outpatient settings, such as urgent care clinics and physician’s offices. A growing trend Dark Daily has covered extensively.

Outpatient Revenue Climbs

In its coverage of the AHA’s study, Modern Healthcare reported that 2017 hospital net inpatient revenue was $498 billion and net outpatient revenue was $472 billion.

The Becker’s Hospital CFO Report notes that gross inpatient revenue in 2017 was $92.7 billion higher than gross outpatient revenue. But in 2016, gross inpatient revenue was much further ahead—$129.5 billion more than gross outpatient revenue. The “divide” between inpatient and outpatient revenue is narrowing, Becker’s reports.

The graphic above illustrates the shrinking gap between hospital inpatient and outpatient revenues. “Outpatient revenue will ultimately eclipse inpatient revenue,” Chuck Alsdurf, Director of Healthcare Finance Policy and Operational Initiatives at the Healthcare Financial Management Association (HFMA), told Modern Healthcare. (Graphic copyright: Modern Healthcare/AHA.)

 The Becker’s report also stated:

  • Admissions increased by less than 1% to 34.3 million in 2017, up from 34 million in 2016;
  • Inpatient days were flat at 186.2 million;
  • Outpatient visits rose by 1.2% to 766 million in 2017; and,
  • Outpatient revenue increased 5.7% between 2016 and 2017.

Similar Study Offers Additional Insight into 2018 Outpatient Revenue

A benchmarking report by Crowe, a public accounting, consulting, and technology firm, which analyzed data from 622 hospitals for the period January through September of 2017 and 2018, showed the following, as reported by RevCycleIntelligence:

  • Inpatient volume was up 0.6% in 2018 and gross revenue per case grew by 5.3%;
  • Outpatient services rose 2.4% in 2018 and gross revenue per case was up 7.1%.

Physicians’ Offices Have Lower Prices for Some Hospital Outpatient Services

Everything, however, is relative. When certain healthcare services traditionally rendered in physician’s offices are rendered, instead, in hospital outpatient settings, the numbers tell a different story.

In fact, according to the Health Care Cost Institute (HCCI), the price for services was “always higher” when performed in an outpatient setting, as compared to doctor’s offices.

HCCI analyzed services at outpatient facilities as well as those appropriate to freestanding physician offices. They found the following differences in 2017 prices:

  • Diagnostic and screening ultrasound: $241 in physician’s office—$650 in hospital outpatient setting;
  • Level 5 drug administration: $254 in office—$664 in hospital outpatient setting;
  • Upper airway endoscopy: $527 in office—$2,679 in hospital outpatient setting.

One example where hospital outpatient settings provide similar services at increased costs is in drug administration, as the graphic above illustrates. “The difference was higher than I expected. With some services, the price is two or three times higher when rendered in the outpatient setting,” Julie Reiff, HCCI researcher and report author, told Fierce Healthcare. (Graphic copyright: HCCI.)

Medicare Proposed Rule Would Change How Hospital Outpatient Clinics Get Paid

Meanwhile, the Centers for Medicare and Medicaid Services (CMS) has released its final rule (CMS-1695-FC), which make changes to Medicare’s hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs.

In a news release, CMS stated that it “is moving toward site neutral payments for clinic visits (which are essentially check-ups with a clinician). Clinic visits are the most common service billed under the OPPS [Medicare’s Hospital Outpatient Prospective Payment System). Currently, CMS often pays more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.”

“CMS is also proposing to close a potential loophole through which providers are billing patients more for visits in hospital outpatient departments when they create new service lines,” the news release states.

Hospitals are fighting the policy change through a lawsuit, Fierce Healthcare reported.

In summary, clinical laboratories based in hospitals and health systems are in the outpatient as well as inpatient business. Medical laboratory tests contribute to growth in outpatient revenue, and physician offices compete with clinical laboratories for some outpatient tests and procedures. Thus, a new site-neutral CMS payment policy could affect the payments hospitals receive for clinic visits by Medicare patients.

—Donna Marie Pocius

Related Information:

AHA Hospital Statistics 2019

AHA Data Show Hospitals’ Outpatient Revenue Nearing Inpatient

Hospitals’ Outpatient Revenue Inching Closer to Inpatient Revenue

“My Net Revenue is Stable,” said No CFO Ever . . .

Revenue Unable Despite Outpatient Volume Growth

Shifting Care from Office to Outpatient Settings: Services are Increasingly Performed in Outpatient Settings with Higher Prices

From Physician Offices to Outpatient Settings and Costs Go Up, HCCI Study Finds

CMS Empowers Patients and Ensures Site Neutral Payment Proposed Rule

Studies Reveal Workers in HDHPs Pay Significantly Higher Annual Healthcare Costs than Employers and May Utilize Fewer Clinical Laboratory Tests

Consumers respond to high-deductible plans by using less healthcare services, which in turn leads to a decrease in doctor visits and clinical laboratory test orders

Are many Americans avoiding medical treatment because of the high-cost of their health plan deductibles? And if so, will such an underutilization of healthcare affect hospitals, independent medical practices such as pathology groups, and clinical laboratories?

Two separate studies: one a survey co-conducted by the Kaiser Family Foundation and the Healthcare Research and Educational Trust (KFF/HRET), and the other an analysis by the Health Care Cost Institute (HCCI), investigated the dynamics behind trends in the healthcare marketplace leading to these questions. (more…)