Managed-Health-Care Complications and Clinical Remedies

Harold J. Bursztajn, M.D.
Harvard Medical School

Archie Brodsky, B.A.
Harvard Medical School

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Harold J. Bursztajn, M.D.
96 Larchwood Drive
Cambridge MA 02138
Phone (617) 492-8366; FAX (617) 441-3195
e-mail: harold_bursztajn@hms.harvard.edu

There has been a growing recognition of the influence of managed health care on the doctor-patient relationship, [1] including the forcing of physicians into an alienating, ethically ambiguous, and clinically conflictual "gatekeeper" role. [2,3] While financial constraints have always been a factor in clinical cases, one major consequence of managed-care practices that seek to influence and control doctor-patient decision-making has been a growing concern as to the lack of meaningful health care choices for both doctors and patients.  The most recent Supreme Court decision, Herdrich v. Pegram, indicated, that at least for now, it is unlikely that judicial rather than legislative action will provide a remedy for the current malaise. [4]

In this atmosphere, patients who face the threat or actuality of a major illness are even more likely to experience heightened feelings of helplessness and hopelessness.  All too often, the precipitant which leads both patients and physicians working in managed-care systems to feel helpless and is a hopeless denial of health-care benefits.  More dangerous still, some patients and which physicians come to distrust each other, as when patients feel physicians are not advocating for them, and when physicians feel patients are "shooting the messenger" (i.e., blaming the physician for managed-care-initiated restrictions).  In this atmosphere, physicians often avoid consideration of treatment alternatives likely to be denied by a managed-care reviewer, or feel compelled to focus on the catastrophic in the differential diagnosis to obtain otherwise denied benefits. [5] The final stage of this downward spiral of the physician-patient relationship in managed-care settings can be a kind of mutual resignation, where the patient leaves with resentment while the physician tries to justify and rationalize the defacto, unconsented, rationing of health care.

Defacto managed care organization healthcare rationing need not be taken as a fait accompli.   Even in it its denial of a patient's claim against managed care organization, the Supreme Court noted that the lack of informed consent or disclosure of physician incentives was a potential cause for action.  While there is a need for legislative action to enable managed-care reform, we cannot and need not wait for such reform to take place before we begin to restore healing relationships.  A variety of useful clinical interventions can be implemented to recover a sense of choice in the doctor-patient relationship.  These can include effectively informing the patient of potential financial incentives to being denied care, and also prepare them to anticipate, identify, and respond to the distress that is likely to accompany managed care restriction of clinical care.

Case Example: Overcoming Managed-Care-Influenced Alienation Through Consultation

One potential intervention, a second opinion or other specialized consultation, was used in the following case to support a strained physician-patient relationship in a managed-care milleu.  In most instances, however, a skilled physician may be able to effectively overcome this by using existing clinical skills to cope with managed-care influences  and achieve the goal of maintaining an alliance without resorting to such a consultation.

Ms. A., a 60-year-old woman who was a child survivor of the Holocaust, had been in therapy with me for over a decade.  She had a 30-year history of cigarette smoking, although she had not smoked for the past 10 years.  She also suffered from a partially resolved chronic Post-Traumatic Stress Disorder (PTSD) due to the aftermath of her horrifying Holocaust experiences.  Recently, after a two-month history of coughing and wheezing, Ms. A. became concerned that she was at risk for developing lung cancer.  However, her request for a CT scan of her lungs was initially denied by her primary-care physician, an employee of a health maintenance organization (HMO), who instead authorized only chest x-rays.  Having previously completed treatment with me for the most restrictive of her PTSD symptoms and complications, Ms. A felt comfortable returning to seek my assistance in resolving the impasse.   In the course of our united exploration, it became clear that the issues raised by her physician's refusal to authorize the CT scan were not financially frustrating.  Ms. A. and her husband were major contributors to medical charities, and were also willing to pay for the costs of the tests out of their own pockets.  The frustrations, rather, were due to her feelings that she was being abandoned again (as in the Shoah) and that she was helpless.  This feeling of helplessness was causing her to undermine her trust in her primary care physician.  After exploring these issues, we composed the following letter together:

Dear Dr. _________:
I am writing to you at the request of Ms. A., your primary-care patient.  It is my understanding that, in view of the recent reports of the usefulness of CT scanning of the lungs for patients with an increased risk of lung cancer, and the high value of early detection for successful treatment, Ms. A. is a good candidate for such screening.  Specifically:

  1. Although she no longer smokes, she is at higher risk since she smoked about 2 ½ packs of cigarettes per day during a 22-year period.
  2. She may have some immune system vulnerabilities, given her chronic Post-Traumatic Stress Disorder as a child survivor of the Shoah. [6]

    At the same time during my ten-year course as her treating psychiatrist, she has been invariably accurate, historically; without a tendency to somaticize or be hypochondriacal.  In fact, on several other occasions, she has been able to effectively identify early warning signs of impending systemic illness.

  3. She has had lower respiratory complaints and upper chest soreness for more than a month.
  4. Even though there is a relatively high likelihood of a negative test result, she is a reliable historian, and like many other PTSD survivors, often has valid intuitions as to early warning symptoms of systemic pathology (gift of fear).   In view of her smoking history, and the reassurance that even a negative test would give her, ordering a CT scan is not only indicated from a pulmonary risk-factor perspective, but is also likely to help with her neuropsychiatric vulnerability to anticipatory anxiety and stress.
  5. Although she is aware of the possibility of a "false positive" as well as a "false negative" test result, she would like to have the opportunity to choose with you how to proceed with whatever information the CT scan can provide.
I have permission from Ms. A. to speak with you. Please feel free to call me if you have any questions. Thank you in advance for your consideration.

Among the features of the letter was the use of literature (in this case a compendium of the studies detailing the long-term medical and psychological consequences of traumas suffered by survivors of the Holocaust) to inform the managed-care gatekeeper, who, in the patient's opinion, seemed to have become overidentified with the managed-care system.  As an additional feature, the letter expressed respect for the patient's own intuitions regarding her physiology as a potential early warning of systemic illness rather than simply being reduced to a mere "blast from the past", a reflection of her PTSD, and simply dismissing her fears.  The primary care physician responded by referring the patient to a pulmonary specialist who enthusiastically recommended a CT scan which proved most helpful in allaying the patient's fears.

Ms. A. paid for her psychiatric consultation with me, out of her own pocket, without aid from any health plan.  Still, not all patients have the requisite financial resources or technical knowledge to seek such consultation.  Although consultation can be helpful in the face of a denial of health-care benefits, it is important that primary-care physicians themselves have the tools and psychological sophistication needed both to advocate for the patient and to support the patient when individually indicated benefits are denied as not "medically necessary." [7]

Patient Dynamics:  "Virtual Captivity"

More generally, an understanding of the dynamics of the physician-patient relationship in the managed-care context can be helpful in adapting one's clinical skills to the task of supporting the patient's capacity for choice, hope, and trust.  For example, even as the prevalence of mental-health problems such as mood and anxiety symptoms in primary-care settings has come to be recognized, [8] the cost-containment strategies of managed health care have been found to inhibit the recognition and treatment of psychiatric disorders in medical treatment settings. [9]  Not only has a diagnosis of depression been found to be associated with patient dissatisfaction with medical care, [10] but patients with high levels of depressive symptoms are less likely than the general population to act on their dissatisfaction by switching health plans. [11] At the same time, the inability to choose one's personal physician has been found to be a major determinant of patients' dissatisfaction with their health-care plan. [12] The existing pool of trapped, frustrated, disillusioned patients also represents a potential tinderbox of litigation in the wake of tragic outcomes associated with managed-care-influenced restrictions on effective care -- in particular, on the building of therapeutic alliances in the doctor-patient relationship.

While the managed health care system amplifies helplessness, the difficulty of maintaining patients' sense of choice in the face of serious illness predates managed care.  Serious illness that threatens an individual's bodily or psychological integrity already poses a threat to a person's sense of autonomy and control.  Serious illness can also heighten dependency while bringing with it feelings of helplessness, hopelessness, and distrust associated with depression.  While diagnosing a medically ill patient with a secondary psychiatric syndrome can be helpful, it is no substitute for a deep understanding with vulnerable patients such as Ms. A., of how distress around illness combined with denial of benefits can become a stressor capable of amplifying symptoms in the Post-Traumatic Stress Disorder spectrum as well as how vulnerable patients' fears of illness should not be dismissed simply as being PTSD, but rather addressed by a thorough diagnosis work up which rules out other potential medical causes for the patient's distress.

When faced first with a lack of choice of health-care provider, and then with restriction or even denial of care, the vulnerable patient, already feeling like a prisoner of the threat of serious illness, may now also begin to feel like a lonely captive of the health care system.  This trapped, "nowhere to turn" feeling may persist after the illness is treated or even cured, for the patient, once burned by the denial of anticipated care or by worry over the prospect of such denial, may come to think, "What if I get sick again?  What care will I receive?" At the extreme, the patient may begin to experience, subtly but significantly, the emotional traumas associated with abandonment [13] and captivity. [14]

Clinically, such experiences can generate anxiety- and depression-driven cognitive distortions which may impair the patient's capacity to temper realism with the hope necessary to tolerate uncertainty and choose wisely from available alternatives as diagnosis and treatment proceed. [4,15]  Moreover, the prospects for a supportive patient-physician alliance are undermined when the physician is seen by the patient either as untrustworthy or as largely powerless to implement his or her own clinical recommendations and protect patient choices under managed-care pressure.  Patient perception of physician trustworthiness may suffer, for example, when managed-care drug formularies restrict the physician from prescribing a medication of choice.  Even a trusting relationship -- especially when it is founded on blind optimism -- can be destroyed by adversity together with perceived abandonment.  As patients' distrust increases, responses can include such modes as "fight" (litigate), "flight" (drop out of treatment), or "freeze" (become numb, passive, demoralized, and unable to act effectively in the interest of one's own health care).  The resulting increase in patients experiencing anxiety and depression can lead both to an even greater likelihood of dissatisfaction with medical care [10] and to an impaired capacity to act on that dissatisfaction by changing health plans. [11]

Physician Dynamics:  "False Necessity"

The human tendency toward either resignation or self-deception and denial of what is too painful to see is not limited to patients.  Often, the treating physician may not have chosen freely to be part of this particular MCO, nor to treat this particular patient, except as the best of a set of undesirable choices or the lesser of necessary evils.  The physician is also likely to have experienced a substantial reduction of economic and professional autonomy in the shift to managed care.  Like the patient, the physician may have few options and insufficient time to recognize, reflect upon, process, and put into perspective the feelings engendered by the need to work in a managed-health-care context.  Under any circumstances physicians are likely to react to a patient's rejection by withdrawing emotionally from the patient.  This reaction is especially likely, however, if the physician faces one frustrated, recalcitrant patient after another in a time-pressured managed-care setting.  At the same time, from the patient's perspective, emotional withdrawal by a hurried and frustrated physician can easily be experienced as indifference to the patient's suffering and perceived as abandonment.

As physicians we are far from immune to the contagion of pessimism that can sweep through an institutional atmosphere, as in end-of-life care.  Physicians who risk being penalized for caring for patients when, in the judgment of an anonymous third-party reviewer, there is no medical necessity to do so are more likely to succumb to institutional pressures.  Careful "not to raise the patient's expectations" by effectively disclosing all possible options and advocating for the patient's right to the best available care, we may automatically "hang crepe"[16] as a prelude to premature discharge.  In the extreme, some clinicians will automatically advise the patient and family that only low-cost palliative measures be taken, not mentioning the more costly, labor and technology intensive alternatives that may, over time, hold out a slim but real hope for the patient's recover.

In this climate there is an increased risk that patients and families will give up prematurely while clinicians too distracted or time-squeezed to do the hard work of eliciting the patient's and family's deeper intentions go through the motions of obtaining informed consent. [17,18] At the same time, some physicians react to their loss of autonomy and choice by making a premature cognitive commitment to diagnostic and treatment decision strategies designed to avoid punitive profiling practices.  For example, a physician who is concerned about being identified as readily willing to hospitalize a patient for observation and evaluation will tend to avoid risking being deselected by the MCO.  This avoidance can manifest itself in the doctor-patient encounter as a fixed, overly rigid stance or a reluctance to present alternatives to the patient other than the treatment least likely to engender MCO scrutiny. Such an attitude interferes with the informed-consent process vital to clinical care.

Of course, some denials of benefits by MCOs do represent a genuine effort to weed out unnecessary treatments and excessive costs.  Nonetheless, other treatments that are medically appropriate (in that they are effective relative to individual patient values) come to be discounted as medically unnecessary by reference to a misguided and self-serving MCO interpretation of "medical necessity" which is insensitive to individual patient values [19] as well as broader health-related social values. [20]  Medically appropriate care is care that is medically indicated based on the doctor-patient dialogue as informed by scientific research and accepted practice.  Ideally, medically appropriate care considers the whole patient. [21] For Ms. A., for example, in view of her physical history, psychological history, and known risk factors, obtaining a CT scan as she requested could be considered medically indicated not only by being reasonably respectful of her informed choice and autonomy, but also by being a reasonable approach to a thorough and intense diagnostic workup for an at-risk patient.

By contrast, the term "medically necessary," as used by third-party reviewers, is a misapplication of triage principles from military and disaster medicine to individual patients. [22] Even treating physicians, when compelled to be time-pressured and hyper-cost-conscious (as in many fixed-fee-per-subscriber capitated systems), tend to narrow their focus to overly concrete, readily measurable "necessary" benefits.  Easily overlooked in such calculations are the costs of incomplete treatment [23] to a patient's freedom to live in the least restricted manner, as well as the biopsychosocial benefits of treatment that considers the patient's overall well-being and level of independent and interdependent functioning.

As physicians we also may find ourselves over-relying on managed-care-driven "practice guidelines."  At least some such guidelines while appearing in the guise of being evidence-based, are all to often used to justify denial of appropriate but expensive care.  Such guidelines are very selective as to the evidence they cite, as in the paucity of studies with outcome measures that reflect quality-of-life issues, or the widespread neglect of many well-grounded outcome studies showing the efficacy of mental health treatment for patients with many medical and surgical conditions.  Thus, although intended as a remedy, guidelines presented under the rubric of evidence-based medicine can be misused as a scientific rationalization for denying care that addresses the existential dimensions of the patient's illness.  When we physicians over-rely on narrow practice guidelines selected, formulated, or funded by MCOs, we compound the problem of benefit and care denial inadvertently validating a misguided use of "medical necessity."  We also always need to remember that decision making for patients in the aggregate is no substitute for individualized clinical decision making.

Prevention and Management of "Managed-Care Side-Effects"

Whether in conjunction with or in the absence of specialized consultation, there are a variety of clinical tools available for prevention and management of the increasing iatrogenic harms experienced (amid life-threatening illness and anticipated denial of benefits and care) as side effects of managed care.  To begin with, it is helpful for the treating clinician to keep in mind the complex interactions between medical and psychiatric disorders that are often obscured by various managed-care influences, such as the lack of time to take a careful history that is objective and empathic.  Although psychiatric consultation or referral is helpful in cases that present special difficulties, it is now less accessible than ever, given the restrictions of managed health care.8  Thus, diagnostically, it is now more important than ever for treating physicians to be aware of psychiatric comorbidity with both acute and chronic physical illness.  These can be exacerbated by the helplessness, hopelessness, and distrust generated by the interaction of the threat of serious illness and the loss of choice exacerbated by managed-care control and restriction of treatment alternatives.  Patient suffering accompanying physical illness can present as depression, "sick role" adaptation, chronic pain, exacerbation of substance abuse or dependence, obsessive or dissociative reactions, and conversion reactions.  In a person who has had a life-threatening illness, such suffering can sometimes rise to the level of disorders in the Post-Traumatic Stress Disorder spectrum. [24]

The flip side of the tendency to overlook psychiatric disorders exacerbated by managed care is the tendency to use psychiatric disorders as convenient labels to rationalize the denial of medical care and neglect the existential dimensions of the patient's suffering.  Thus, it is important not to write off patients in panic as simply hypochondriacal because of time pressure associated with managed care.  As is well accepted, if a person presents with symptoms similar to those that marked a previous life-threatening illness, the physician should first rule out a recurrence of that illness.  When there has been a recurrence, any post-traumatic sequelae need to be attended to, even in the face of managed-care constraints.  These sequelae may include symptoms of depression, demoralization, dissociation, flashbacks (e.g., "Oh, my God, it's happening again!"), and an increased risk of panic and suicide.  In this context a patient's anxiety may become especially amplified by acute somatic symptoms associated with vulnerable body-image areas. [25]

The physician who is aware of these dynamics can avoid succumbing to a triage mentality that dismisses psychiatric symptoms as insignificant22.  Even if a recurrence of the illness has been ruled out, the illness may have left a vulnerability in that the emotional memory of its painful and frightening initial presentation may be reactivated simply by the recurrence of general symptoms, with possible life-threatening complications for the patient such as depression, panic, and increased pain sensitivity, and even suicide or "suicide equivalents."  The latter may include self-medication of panic and pain by excessive drinking or medication overdoses, and counterphobic risk-taking such as driving under the influence.  With the threat of recurrence of the illness, the feeling of being alone and the lack of choice in the managed-care situation can also increase the likelihood of such self-destructive reactions.

Even when practicing in a time- and resource-restricted environment, with access to psychiatric consultation severely limited for patient and physician alike, all treating physicians can be on alert for managed care complications and focus on making emotional contact with patients.  Physicians concerned with making contact will create provisional alliances even when they do not have the usual time, training or ongoing involvement required for sustained alliance building or for providing psychotherapy per se. [26] In whatever wording comes naturally to the individual physician, It is essential to convey certain fundamental understandings and attitudes as the patient-physician alliance needs to be rebuilt as the relationship evolves in a meaningful care context.

Remedies for an Evolving Relationship Under Stress

In the introductory phase of the relationship, the physician can make contact with the patient while observing the patient for indications of a potential (or hidden) but deep sense of helplessness and hopelessness which accompanies the experience of captivity. [14]  At the same time, it is helpful to initiate a meaningful dialogue as a first step toward creating a therapeutic alliance and detoxifying feelings of loneliness and abandonment.  This step can include engaging in an informed-consent process (not merely a pro forma litany of risks and benefits). [4,15]  Such a process needs to address clinical and economic risks and such potential ethical and role conflicts as might be engendered when a clinician is a dual agent, e.g., both a "gatekeeper" and the primary-care treating clinician in a capitated system. [27] By the same token, it is helpful when the clinician can tactfully but effectively disclose all substantial treatment alternatives, including those not covered by the patient's health plan.

These disclosures can enable the patient and physician together to decide how to respond to economic restrictions on treatment without the patient being overwhelmed by anxiety and pessimism precipitated by the illness.  Likewise, if it is reasonably foreseeable at the outset that continuity of care will be interrupted by changes in the patient's insurance coverage, then reminding the patient of how helpful it can be to keep abreast of possible insurance changes will be part of the economic informed-consent process.  In our experience, patients can sometimes influence employers' choice of insurance providers and managed health-care packages.  Subsequently, if a change in coverage is threatened, the physician can support the patient by actively inquiring about how any prospective benefit changes might affect continuity of care.

Given the concern that many patients are coming to distrust their physicians because of managed-care policies, [28,29] it is important to inform the patient sensitively of those economic considerations, such as provider profiling, managed-care guidelines, and capitation contracts, that may affect the quality of care the patient receives.  Openly acknowledging such dilemmas can enhance the possibilities for a therapeutic alliance.  To provide for continuity in sharing uncertainty, it is helpful to articulate questions left open to be addressed in future visits and anticipate which questions may arise before the next visit.  Such open communication, however desirable, cannot be taken for granted in practice.   Although "Gag clauses" [30], which deny the physicians rights to mention treatment alternatives that may not be covered by managed care, have been eliminated as explicit provisions in physician contracts with MCOs, they may be implicitly promoted by MCOs through health-care-provider profiling, economic deselection, and other, often hidden, rules and procedures, and incentives.

In the ongoing care phase, the physician can implement treatment with as much continuity and mutual planning as possible while continuing to respond to managed-care treatment restrictions in light of the patient's evolving attitudes and preferences and changing clinical status.  Treatment can proceed in a manner that respects the patient's best interests, including autonomy interests, without being overwhelmed by considerations such as "How will this affect my profile?"  The physician who needs or wants to apply practice guidelines, as noted above, is also faced with translating what any diagnostic or therapeutic option actually means for this particular patient given the patient's life history and individual values.

In the event of a denial of benefits, every effort needs to be made to continue the relationship and to avoid abandonment.  While the denial of some benefits can reduce the quality of other benefits and of the clinical care the patient receives, it need not result in a catastrophic end to the doctor-patient relationship.  For example, even when indicated hospitalization is denied, the physician can work with the patient on an appeal and remain available throughout the course of treatment to help the patient consider the life choices that chronic illness periodically poses.

By working throughout the benefit denial and appeal processes to maintain as much patient confidentiality as is possible under the circumstances, the physician can avoid feeling pressured into entering into "secret" manipulative agreements with the patient, such as to select for billing purposes from among the differential diagnoses those that increase the likelihood of receiving managed-care benefits.  Physicians who feel their only recourse is either to "spin" [31] (reduce diagnostic uncertainty and complexity in a favorable direction for reimbursement) or even to lie for their patients [32] are often expressing the underlying helplessness and hopelessness they themselves feel.  Such secrecy and misalliance based on deceiving the MCO can all too readily undermine the trust necessary for the doctor-patient relationship to be open and healing.  "If my doctor is willing to lie for me, might not my doctor also be willing to lie to me?" is a natural question implicit in the growing dissatisfaction of patients with the health care system.  Moreover, a relationship built around secrecy and deception, rather than confidentiality and open commitment, is vulnerable to a sudden, panicked withdrawal by a guilt-ridden physician, culminating in abandonment.  Further research is needed to elucidate whether the secrecy engendered by managed-care intrusiveness, such as physician-patient collusion around diagnosis or billing, can also be an additional risk factor for boundary violations.  It is reasonable to inquire whether secrecy will eventually have negative consequences in the doctor-patient relationship similar to those it has been observed to have in family relationships. [33]

The termination phase is critically important in any clinical relationship in which an emotional bond has been formed.  Prior to the patient's transferring to another care provider, it is helpful to consider what choices the physician and patient have made together, what other choices they might have made, and how managed-care pressures may have influenced those decisions. The physician whose contract is terminated by an MCO can inform the patient as to the MCO's action and coordinate the transfer of care to the new physician while supporting a patient's choice to take steps to oppose involuntary termination.  In cases where involuntary termination is brought about by the patient's employer changing its health plan, the physician can attend actively to both the practical and emotional aspects of termination.

The opportunity for a meaningful goodbye needs to be preserved even when the goodbye is relatively involuntary.  The physician need not allow feelings of anger and frustration toward the MCO to become displaced onto patients, leading to abandonment via failure to inform patients of the foreseeable consequences of "involuntary" abrupt termination.  When the process of saying goodbye is properly attended to, even an involuntary termination of a relationship can be borne without sliding into an abyss of abandonment and paralysis.

Summary

Ethically, even under managed-care constraints, the physician has a duty to provide effective and compassionate care.  Irrespective of the structure of health-care delivery, the physician retains a primary duty to advocate for the patient's interests, including the right to make informed choices based on effective disclosure of treatment options.3  This duty is made all the more salient, in a historical context, by the emerging recognition of the importance of maintaining an informed-consent process when patients are captives, whether literally or only figuratively. [34]

Although clinical intervention is no substitute for instituting fundamental changes in health-care financing and regulation of third-party control, even today the ethically sensitive, psychologically sophisticated physician practicing in a marketplace dominated by managed care need not feel too overwhelmed on the individual doctor-patient level to perform damage control.  By identifying and then preventing or alleviating the negative biopsychosocial side effects of the restriction of available patient choices, a substantial reduction in the clinical complications of managed care organizations' control and denial of patient choice and care can be achieved.

As malpractice risk management, attention to the clinical process can also be a preventive or antidote for an increased likelihood of malpractice liability in the event of a tragic outcome.  Both bad medical outcomes, reasonably attributable to MCO-initiated distractions from a clinical focus on the patient's best interests, and bad feelings arising from managed-care restrictions on patient autonomy tend to feed malpractice risk.1  Moreover, attention to the clinical process allows physicians and patients to appropriately initiate, proceed with, and terminate relationships even when each phase of the relationship is subject to significant managed-care control.

In the realm of public policy, well-intentioned reforms may misfire if undertaken without benefit of a deep clinical understanding of the dynamics of lack of choice.  Medical outcomes are affected not only by the quality of technical care given, but also by the process of care, including patient participation in decision making. [35] Denial of choice reduces quality of care in that the patient loses both the psychological benefits of exercising choice and the medical benefits of individualized treatment.  Enhancing choice and autonomy for both patient and physician can help restore trust between them and improve the quality of the available health-care benefits.

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