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The Reduction of Medical Waste Through Value-Based Care Organizations: Solutions for

Unnecessary Spending in United States Healthcare

By Arsh Shah

Lake Forest College Economics Department


August 21st, 2015
BUSN 490
Advisors: Professor S. Aneeqa Aqeel & Professor George Seyk

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The most abundant issues in the medical field today deal with transparency, unnecessary
care and over-utilization, and patient outcomes. Each of these topics is respectively caused by a
major flaw known as fee-for-service, present in modern day primary care practices and hospitals.
In turn, fee for service diminishes transparency, boosts unnecessary care and over-utilization, and
decreases good patient outcomes. Furthermore, this idea denotes that patients are charged
separately for each service provided to them at their doctors office or hospital, instead of
otherwise bundling the procedures and increasing overall cost-effectiveness for these patients
and their families. When compared to Oak Street Health clinical models, we find that FFS is
decreased substantially, as Oak Street lowers co-pays for patients, bundles treatments and
provides greater amenities (transportation, patient support and events), and focuses on its sickest
Medicare and Medicaid patients, all for a lower cost. Typical fee-for-service (FFS) practices
create incentives for physicians to focus on quantity of care (as they bring in more profit with a
higher number of tests and visits), rather than the quality of care. Research shows that alternative
payer models (such as those at Oak Street Health) outside of fee-for service have the potential to
save millions of dollars by preventing over-utilization, whilst increasing transparency and patient
outcomes, creating better spending habits, and providing better patient care in the long run. All
of the current issues we face result in an extremely significant amount of money wasted in the
medical profession.
What follows hereafter is an analysis of said waste in the medical system as a result of
these unnecessary admissions and procedural issues. More specifically we will delve into a
historical break down of the effects of the fee-for-service and its contribution to waste on an
international and local scale. Two main sources addressing the medical waste will be consulted:

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statistics and data from the Center for Medicare and Medicaid services and the medical thinking
of healthcare researcher, author, and surgeon Atul Gawande (a prominent writer for The New
Yorker). Also, the Affordable Care Act will be dissected to see if how it contributes to better
patient care and more efficient health care. Finally, conclusions will be drawn comparing the Oak
Street Health clinical model to the typical FFS model, as well as regular primary care practices
against updated Oak Street Health managed care frameworks, as described prior.
Firstly, it is important to historically examine the regular aspects of fee-for-service that
the United States has come to accept over the past few years. The seemingly harmless FFS
concept was responsible for an estimated $750 billion dollars in unnecessary spending in the year
2009.1 This roughly translates to thirty cents of every American dollar contributing to medical
waste and unnecessary care, albeit of low quality. The overall breakdown of waste is as follows:
$210 billion for unnecessary care, $190 billion for excessive administrative costs, $130 billion
for inefficient delivery of care, $105 billion for inflated prices, $75 billion for fraud (from
insurance companies, clinicians and patients), and $55 billion from missed prevention
opportunities.2 Mark Smith, the chairman of the IOM (and a former expert advisor to President
Clintons Task Force on Healthcare Reform) said that our current state of healthcare is driven by
a maddening paradox, in which patients are over-treated (creating medical waste) or undertreated (creating lower life expectancies).3 This proves a strong point in the healthcare debate
Quinn, Audrey. 2012. 'The Top Causes Of U.S. Health Care Waste | Zdnet'. Zdnet. http://
www.zdnet.com/article/the-top-causes-of-us-health-care-waste/.
1

Ibid.

Smith, Mark. 2012. Best Care At Lower Cost: The Path To Continuously Learning Healthcare
In America. Ebook. 1st ed. California: Institute of Medicine of the National Academies. http://
iom.nationalacademies.org/~/media/Files/Activity%20Files/Quality/LearningHealthCare/Release
%20Slides.pdf.
3

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today: the difference between necessary and unnecessary care is too marginal. Doctors and
hospitals cross the line between care that is critical (true preventative care), and care that should
be done just to be safe. As a result, [we] spend more than twice as much per person on
healthcare as all other industrialized countries, despite being the only country that doesn't
provide basic health insurance for its citizens.4, says Dr. Timothy Johnson, a senior medical
contributor for ABC News. From an economic standpoint, if doctors are focused on becoming
richer at the expense of patient care, the medical profession becomes oversaturated and
healthcare drops in quality nationwide.
In 2014, the United States spent eighteen percent of its gross domestic product on health
care, compared to the Netherlands who had only spent twelve percent. In terms of scale, the
United States GDP amounted to around $17 trillion last year, leaving that six percent in gap
spending to be around an additional $1 trillion dollars out of the US government budget.
Household-wise, the estimated waste per household amounts to more than $8000 per family
(through insurance premiums, taxes, out of pocket care, and other costs.)5 The simple
explanation for a big proportion of this spending, aside from unnecessary care and overutilization, is that the United States has a large number of specialists that engage in high tech
practices like imaging and other diagnostics.

Wong, Julielynn. 2012. 'US Health System 'Wasted' $750B In '09'. ABC News. http://
abcnews.go.com/blogs/health/2012/09/06/us-health-care-system-wasted-750-billion-in-2009/.
The Atlantic,. 2014. 'Why Do Other Rich Nations Spend So Much Less On Healthcare?'. http://
www.theatlantic.com/business/archive/2014/07/why-do-other-rich-nations-spend-so-much-lesson-healthcare/374576/.
5

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On an international level, the Organization for Economic Co-operation and Development
recognized the following:

Compared with the average OECD country, the U.S. delivers (population adjusted)
almost three times as many mammograms, two-and-a-half times the number of MRI scans, and
31 percent more C-sections. Also, the U.S. has more stand-by equipment, for example, 1.66 MRI
machines per 6,000 annual scans vs. 1.06 machines. The extra machines provide easier access for
Americans, but add to cost. Similarly, occupancy rates in U.S. acute care hospitals are much
lower than in OECD countries, reducing the likelihood of delays in admissions, but building that
extra capacity adds to cost. 6

While seemingly more thorough and convenient, these high-tech practices can contribute to
waste as well as add to our expenses. In addition to spending twice as much, we also cannot
control administrative pressures as our government doesn't have strong tax supported healthcare
with more government intervention. According to Victor Fuchs, a PhD candidate at the Stanford
Institute for Policy Research:

The larger role of government in health in OECD countries and the difference in mix of
services are the main proximate explanations for the higher level of spending in the United
States. Because funding in most OECD countries is usually through a tax-supported system,
administrative costs are usually much lower than in the United States, with its fragmented
sources of funding and payment. Also, the OECD countries use the concentration of funding to
negotiate aggressively with drug companies and physicians and to control investment in hospitals
and equipment. The United States could try to use the buying power of Medicare in a similar
way, but legislation and political pressure prevent such an approach.7
The specialists that engage in more high tech care, as mentioned earlier, make more
money and also have a more considerable influence on policy. Also, we can safely assume that

Ibid.

Fuchs, Victor R. 2013. "How and why US health care differs from that in other OECD
countries." JAMA: Journal Of The American Medical Association 309, no. 1: 33-34. PsycINFO,
EBSCOhost (accessed August 18, 2015).
7

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quite often those on public healthcare (Medicare/Medicaid, often those of lower socioeconomic
status), believe that more expensive care translates to better care. 8 Drug costs in the US are about
twice as much as those in other countries. Specialist physician fees are also twice or even worse,
three times as high. Lower prices abroad are found by governments who pay for up to seventyfive percent of medical care, whereas the US government pays about fifty percent.9 Fuchs
solution is quite difficult to put into practice, so we need to find another method of reducing our
spending.
Local information compared to the national average from the Center of Medicare and
Medicaid Services shows that inpatient costs (i.e hospital admit/procedural costs) for various
procedures can range from a fraction of the national average to up to more than twice the cost,
depending on the severity of the procedure. The most recent data set, entitled Medicare Provider
Utilization and Inpatient Charge Data: FY (Fiscal Year) 2013, outlines some notable statistics
for Lake Forest Hospital when compared to Northwestern Memorial in downtown Chicago. For
example, in 19 cases of surgery of intracranial hemorrhage or cerebral infarctions with
complications and comorbidities (CC) or major complications and comorbidities (MCC), Lake
Forest Hospital billed Medicare an average of $38,318, which is 1.3 times the national average
billed for this procedure. In return, Medicare paid a mere $7,335, which is 0.9 times the national
average paid to hospitals. When looking at the same procedure for Northwestern Memorial, we
see an average amount billed for 56 cases of $110,418, which is 2.2 times the national average.

The Atlantic,. 2014. 'Why Do Other Rich Nations Spend So Much Less On Healthcare?'. http://
www.theatlantic.com/business/archive/2014/07/why-do-other-rich-nations-spend-so-much-lesson-healthcare/374576/.
8

Ibid.

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In return, $23,337, a staggering 1.7 times the national average, is paid back by Medicare. 10 The
cost of such fee for service practices is is extremely variable and this is dependent on various
quality metrics for medical care (as the costs are most likely risk adjusted by age, disability,
socioeconomic status, disability, geography, and whether or not a condition constitutes a chronic
illness or not). Therefore, with different socioeconomic areas, fee for service costs may
drastically vary, with those in poorer areas (such as the South side of Chicago) billing Medicare
more for procedures. When compared to a financially sound area (Lake Forest), its easy to see
how costs can skyrocket with such complicated procedures (leading to low quality care).
Atul Gawande is perhaps one of the foremost authorities on healthcare policy and
research and is also an author, a surgeon for Harvard Medical School, and a columnist for The
New Yorker. Gawande has written breakthrough articles on unnecessary care and over-utilization
in the past six years, namely: The Cost Conundrum (2009), The Hot Spotters (2011), and
Overkill (2015). His first work, The Cost Conundrum sheds some light on questionable medical
practices in low income areas, and provides some ideas to solve the issue of medical waste.
These solutions largely influenced the creation of the various principles present throughout Oak
Street Health, which has been deemed an a value-based care organization.
The small town of McAllen, Texas is the subject of examination in this article as it has
the lowest household income in the country, but has one of the most expensive healthcare
markets. In 2006, Medicare spent fifteen thousand dollars per enrollee in McAllen, which was
twice the national average at the time. In harsh criticism of the the vast overcharging due to
Center of Medicare and Medicaid Services,. 2015. 'Medicare Provider Utilization And
Payment Data: Inpatient - Centers For Medicare & Medicaid Services'. https://www.cms.gov/
Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-ProviderCharge-Data/Inpatient.html.
10

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advanced machines, doctors have turned to overuse of medical equipment and testing for
personal profit. Medicine has become a pig trough here.[we] took a wrong turn when doctors
stopped being doctors and became businessmen.11 This is nothing new to what weve seen when
examining data from CMS or typical healthcare FFS models, but it is important to note a case so
extreme that in some ways it seems like outright fraud. Since the Mayo Clinic model was
introduced (high quality care, lower costs), Gawande tells us that it is on the decline: many
people in medicine dont see why they should do the hard work of organizing themselves in
ways that reduce waste and improve quality if it means sacrificing revenue.12 The solution is to
shift towns like McAllen back to the accountable care organization (ACO) model (like the Mayo
Clinic): in which doctors collaborate to increase prevention and quality of care, while
discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach,
insurers whether public or private would allow clinicians who formed such organizations
and met quality goals to keep half the savings they generate.13 Although, somewhat far-fetched,
this concept has proved quite effective in healthcare today, with companies like Oak Street
Health. The profit margins are much smaller, but the work is more rewarding in terms of
personal satisfaction.
The second article by Gawande, The Hot Spotters (2011), talks about growing crime rates
in Camden, New Jersey and a doctors effort to apply them for use in the medical profession. As
Camden is a poor economic area, crime rates have been climbing quickly. In this case, Dr. Jeff

Gawande, Atul. 2009. 'The Cost Conundrum - The New Yorker'. The New Yorker. http://
www.newyorker.com/magazine/2009/06/01/the-cost-conundrum.
11

12

Ibid.

13

Ibid.

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Brenner took computerized crime maps that were color coded for high crime areas and re-coded
them to provide hospital costs for residents. The statistics that Brenner discovered were
staggering. [Brenner] found that between January of 2002 and June of 2008 some nine hundred
people in two buildings accounted for more than four thousand hospital visits and about two
hundred million dollars in health-care bills. One patient had three hundred and twenty-four
admissions in five years. The most expensive patient cost insurers $3.5 million.14 Interestingly
enough, these individuals were suspected to be receiving the worst care. Furthermore, one
percent of Camdens one hundred thousand patients (only a thousand patients), made up thirty
percent of the citys healthcare cost. Therefore, to alleviate some of this cost, Brenner helped the
sickest patients in hospitals get back on track (those who had 5-6 different chronic conditions at
the same time). So, with each patient getting healthier with the effective aid of this critical one
percent, Brenner was saving the community hundreds of thousands of dollars.
Another instance is present at the Special Care center in Atlantic City, under a program
created by Harvard internist Rushika Fernandopulle. Instead of typical FFS, he created a flat
monthly fee per patient, eliminating large billing paperwork charges, unlimited free access to the
clinic every month without additional cost, guaranteed same day appointments, no co-pay or
insurance bills, and goal tracking for every patient. Full time health coaches were also hired to
work with patients to manage their health.15 As another inspiration for Oak Street Health,
Fernandopulles practices are still in use today. Although more expensive than traditional
primary care models, these practices show that more meaningful care is given to the sickest
Gawande, Atul. 2011. 'Finding Medicines Hot Spots'. The New Yorker. http://
www.newyorker.com/magazine/2011/01/24/the-hot-spotters.
14

15

Ibid.

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patients. Furthermore, because patients were taking their medications regularly, drug costs
increased. Gawande compares these changes to the statistical phenomenon known as
regressions to the mean, the idea that higher cost patients have headed towards better
healthcare on their own.16
The final article written by Atul Gawande, entitled Overkill (2014) is perhaps his
magnum opus, directly addressing the unnecessary care epidemic and proposing solutions for its
complete reorganization and upheaval. After investigating the issues in McAllen, Texas (The
Cost Conundrum, 2009), Gawande decided to revisit the town to see what had changed.
Medicare costs per person had dropped to $12,000 between 2009 and 2012. After working with
again with economist Jonathan Skinner, of the Dartmouth Institute for Health Policy and Clinical
Practice, Gawande found that these savings projected to over half a billion dollars by 2014.
Furthermore, McAllen was introduced to WellMed, an ACO that pitched the following concept
to clinicians: if a doctor improved care quality, cost would be saved, and a percentage of that cost
would be given back to the doctor in the form of bonuses - also known as shared savings - as
mentioned prior.17 Shared savings proves to lower expenditure growth by trying to eliminate any
care that is unnecessary. Of course, by providing less care, healthcare professionals must still
make sure to understand that they do not fail to provide all the care that is needed for a patient. In
this regard, there is a fine line between the extremities of too little care and too much care, which
should be taken into account as well. Gawandes perspectives built a strong foundation for
healthcare policy nationwide (Obamacare) as well as practices put in place at Oak Street Health.
16

Ibid.

Gawande, Atul. 2015. 'Americas Epidemic Of Unnecessary Care'. The New Yorker. http://
www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
17

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The Affordable Care Act is law that was put into place on March 23rd, 2010 by President
Obama, set on creating new mechanisms for reform over time. These new changes include a
Patient Bill of Rights to protect from insurance abuse, cost-free preventative care, the creation of
accountable care organizations, open enrollment in the health insurance marketplace, and
affordable care for those in low or middle class families.18 It will provide billions of previously
uninsured people insurance coverage and tax credits towards their healthcare cost, and will
definitely aid those in lower income communities.
In Illinois specifically, 349,487 consumers selected or were automatically re-enrolled in
affordable coverage, and 11.7 million consumers were nationally re-enrolled automatically in
2015. Furthermore, Gallup polls recently announced that uninsured rates were down to 11
percent this year, changing from 15.5 percent in 2013.19 In total $332,442,046 was given to
Illinois since the ACA was created, and that has gone towards ending discrimination for preexisting conditions, create focused initiatives on tobacco cessation, obesity prevention, health
coverage enrollment assistance, and increasing the primary care and public health workforces,
among other causes. 20 These shifts, although not instantly implemented, will definitely drive
lasting change. The most notable and perhaps useful addition to recent healthcare policy is the
idea of a value-based care organization. In our case, Oak Street Health provides an innovative
platform for Medicare patients (over the age of 65).

18

Health and Human Services,. 2015. 'Key Features Of The Affordable Care Act By Year |
HHS.Gov/Healthcare'. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html#2012.
19

Health and Human Services,. 2015. '5 Years Later: How The Affordable Care Act Is Working
For Illinois | HHS.Gov/Healthcare'. http://www.hhs.gov/healthcare/facts/bystate/il.html.
20

Ibid.

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Oak Street Health is a value-based care organization that has a network of insurance
providers (Blue Cross Blue Shield, Humana, etc), furthermore contains managed care models
(preferred provider organizations, also known as PPOs, and health maintenance organizations,
or HMOs). Seventy five percent of Medicare relies on the fee for service (FFS) model, and the
remaining twenty five percent on these alternative models(PPO/HMO). Furthermore, research
suggests that HMOs are more able to cut over-utilization cost by 20 or 30 percent when
compared to typical FFS models. [These] findings demonstrate that the more managed plans do
not compromise quality. [They do] just the opposite: they deliver higher-quality care than feefor-service medicine and thus do a better job of improving health care value.21
The Oak Street Health clinical model fits the mold for a value-based care organization.
Focused on those primarily with Part B Medicare, Oak Street accepts traditional Medicare (FFS)
and Medicare Advantage as well (Part C), and contracts with varied insurance providers.. After
finding that complex, chronic older patients drive the cost of Medicare (20% of 65+ patients
create 75% of the cost - an estimated $350 billion)22, a tier system was created for the sickest
patients based on need and acuity (similar to the Fernandopulle system). The tiers are assessed
during the first two visits and are assigned as good (0-30% sickness), fair (31-70% sickness),
serious (71-95%), or critical (96-100% sickness), which dictate how frequently patients are seen
(anywhere from every 3-4 months or up to twice a month). Those in serious or critical condition

Kaplan, Jon, Jan Kuenen, Mike Pykosz, and Stefan Larsson. 2013. 'Alternative Payer Models
Show Improved Health-Care Value'. Boston Consulting Group. https://
www.bcgperspectives.com/content/articles/
health_care_payers_providers_alternative_payer_models_show_improved_health_care_value/.
21

22

Oak Street Health Internal Analysis

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are given priority with 24/7 MDs as well as transportation and home visits, etc.23 Another
advantage is smaller scale care.
Instead of the typical Medicare approach (where a patient would see 7 physicians, 2
primary care physicians, across 4 different practices), a patient is surrounded by a small managed
care team (an MD and 4 other members) with Oak Street acting their primary care doctor. This
clinical model leads to improved health, for patients using emergency response (41% FFS
compared to just 20% for Oak Street), undergoing diabetic amputations (1.2% FFS compared to
just 0.03% for Oak Street), and open heart surgery (3.7% FFS, compared to just 1.9% for Oak
Street).24 The core preventative care model tries to reduce emergency response need with home
visits, 24/7 consultation, connecting emergency response with Oak Street MDs, and working
with hospital staff to facilitate discharge in the event that patients need to go to the hospital. As
Oak Street has such a groundbreaking alternative payer model, tiered patient systems, and a
small scale managed care ideology, they are left to focus on patient satisfaction and outcome,
which is perfect for the effective creation and expansion of their business.
Finally, an important source to draw on is that of the Dartmouth Atlas of Healthcare,
which provided fee for service Medicare reimbursement data from 2012 based on price, age, sex
and race throughout Illinois. Chicago is found to have reimbursed averages into a group of 30
hospitals at $11,017 per Medicare enrollee per year, with reimbursements on hospitalizations
averaging at $5,234 dollars per year. Given the practical application of these values into the Oak
Street model, an estimated $4076.29 is saved (37%), putting the reimbursed fee-for service

23

Ibid.

24

Ibid, 2013.

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average at $6,940. In terms of hospitalization, $5,234 - $1936.58 (saved) is equal to $3297.20
reimbursed. These large savings per enrollee can add up to potential millions of dollars saved at
the national level. In terms of admits per 1000 patients, the city of Chicago has 321, compared
to Oak Street who has 202, a notable 63% less. 25
To end, we see that the medical waste issue in healthcare today can be attributed to a
multitude of factors, namely transparency, over-utilization, and disregard for patient well being.
Given updated alternative payer models, patient tiering, and value-based care, we see an
effective solution to minimizing the waste in healthcare costs. So, can value-based organizations
like Oak Street Health become a long term solution to the healthcare cost crisis in the United
States? They definitely reduce the amount of medical waste and increase overall patient health,
reducing hospital readmissions, and providing stronger care to patients. If the future of American
healthcare models adopts updated administrative technologies, more emphasis on acute care for
patients and focuses on preventative care, the country will definitely cut back on spending and be
taking steps in the right direction to resolve the healthcare crisis.

25

Ibid.

!15
References
Center of Medicare and Medicaid Services,. 2015. 'Medicare Provider Utilization And Payment
Data: Inpatient - Centers For Medicare & Medicaid Services'. https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/
Inpatient.html.
Colliver, Victoria. 2015. 'Waste In U.S. Health Care System'. Sfgate. http://www.sfgate.com/
health/article/Waste-in-U-S-health-care-system-3845880.php.
Gawande, Atul. 2009. 'The Cost Conundrum - The New Yorker'. The New Yorker. http://
www.newyorker.com/magazine/2009/06/01/the-cost-conundrum.
Gawande, Atul. 2011. 'Finding MedicineS Hot Spots'. The New Yorker. http://
www.newyorker.com/magazine/2011/01/24/the-hot-spotters.
Gawande, Atul. 2015. 'Americas Epidemic Of Unnecessary Care'. The New Yorker. http://
www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
Gengler, Amanda. 2014. 'Are You Paying For More Health Care Than You Need? Probably.'.
MONEY.Com. http://time.com/money/2791570/are-you-paying-unnecessary-health-care/.
Health and Human Services,. 2015. 'Key Features Of The Affordable Care Act By Year |
HHS.Gov/Healthcare'. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html#2012.
Health and Human Services,. 2015. '5 Years Later: How The Affordable Care Act Is Working For
Illinois | HHS.Gov/Healthcare'. http://www.hhs.gov/healthcare/facts/bystate/il.html.
Hixon, Todd. 2015. 'Why Are U.S. Health Care Costs So High?'. Forbes. http://www.forbes.com/
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Money'. PBS Newshour. http://www.pbs.org/newshour/rundown/what-could-750-billion-wastein-us-health-care-buy/.

!16
Kaplan, Jon, Jan Kuenen, Mike Pykosz, and Stefan Larsson. 2013. 'Alternative Payer Models
Show Improved Health-Care Value'. Boston Consulting Group. https://
www.bcgperspectives.com/content/articles/
health_care_payers_providers_alternative_payer_models_show_improved_health_care_value/.
Kelto, Anders. 2015. 'Family Doctors Who Do More, Save More'. NPR.Org. http://www.npr.org/
sections/health-shots/2015/05/11/405955775/family-doctors-who-do-more-save-more?sc=tw.
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Spending'. http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml.
Quinn, Audrey. 2012. 'The Top Causes Of U.S. Health Care Waste | Zdnet'. Zdnet. http://
www.zdnet.com/article/the-top-causes-of-us-health-care-waste/.
Smith, Mark. 2012. Best Care At Lower Cost: The Path To Continuously Learning Healthcare In
America. Ebook. 1st ed. California: Institute of Medicine of the National Academies. http://
iom.nationalacademies.org/~/media/Files/Activity%20Files/Quality/LearningHealthCare/Release
%20Slides.pdf.
The Atlantic,. 2012. 'How The U.S. Health-Care System Wastes $750 Billion Annually'. http://
www.theatlantic.com/health/archive/2012/09/how-the-us-health-care-system-wastes-750-billionannually/262106/.
The Atlantic,. 2014. 'Why Do Other Rich Nations Spend So Much Less On Healthcare?'. http://
www.theatlantic.com/business/archive/2014/07/why-do-other-rich-nations-spend-so-much-lesson-healthcare/374576/.
The Dartmouth Atlas of Health Care,. 2015. 'Total Medicare Reimbursements Per Enrollee, By
Adjustment Type - Dartmouth Atlas Of Health Care'. http://www.dartmouthatlas.org/data/
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ind=225&tf=34&ch=191&loc=15,70,82,83,103,130,135,166,181,216,260,281,314,340&loct=3
&addn=ind-226_ch-191_tf-34&fmt=264.
Wong, Julielynn. 2012. 'US Health System 'Wasted' $750B In '09'. ABC News. http://
abcnews.go.com/blogs/health/2012/09/06/us-health-care-system-wasted-750-billion-in-2009/.

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