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Health Care Service Quality A Comparison of Public and Private Hospitals
Subject
Students Name
Institution of Affiliation
Date
Health Care Service Quality: A Comparison of Public and Private Hospitals
Introduction
According to research, there is a significant relationship between quality service delivery, customer satisfaction, loyalty, customer retention, profitability, costs, service guarantee as well as the financial performance of the service business. Service quality is an elusive and abstract concept which is difficult to measure and define, unlike products whose quality can be measured. Service quality according to Berry et al. (1988) can be defined as the conformance to the customer specifications. The interactive nature of the services process results of the client’s evaluation of quality immediately after the provision and performance of the particular services and this makes performance to be one of the most important and competitive weapon in the service business.
SERVQUAL is the most widely used tool in the measurement of service quality and was based on the disconfirmation model that proposes that satisfaction is a function of disconfirmation of perception from expectation. The assessment tool was founded on the perspective that the client’s assessment of service quality was paramount, conceptualizing the assessment as a gap that existed between what the customers expect from a class of service providers and the evaluations of the performance of a certain service provider. The SERVQUAL tool measures the service quality in five dimensions that include; responsiveness, tangibles, assurance, reliability, and empathy by 22 items and each of the items are written twice. The initial writing is to determine the expectations of the customer from the service provider while the other writing is to measure the perceptions of the performance of a particular firm.
Service quality in the health care industry
The health care service is broken down into two quality dimensions that include; functional and technical quality. Technical quality is defined based on the technical accuracy of the medical diagnosis and procedures or the conformance to the professional specifications, and it refers to what the customers get. Functional quality, on the other hand, can be defined as how the health care services are delivered to the patients, basically referring to how the customers obtain the services. Most of the patients lack the knowledge of effectively evaluating the quality of the diagnostic and therapeutic intervention process and this explains why the technical quality falls short of being a beneficial measure for describing how the patients evaluate the quality of medical services. Due to this, patients tend to base their evaluation on quality on the interpersonal and environmental factors, to which are taken less seriously by the medical professionals. Most of the patients, however, cannot differentiate between the caring and the curing performance of medical care providers.
Research objectives
Three objectives were used in the study
1. To test the dimensionality of the SERVQUAL instrument in the Northern Cyprus health care industry.
2. To assess the service quality provided in public and private hospitals in Northern Cyprus.
3. To identify the service quality dimensions which play important role in customer satisfaction.
Materials and methods
Data was collected in two phases; through questionnaires that consisted of four parts and the evaluation of the three parts in the questionnaire. The sample was drawn from the people living in northern Cyprus aged 18 years and above. Sample size determined as 990 with a 95% confidence level. The data collection process was conducted by KADEM, a professional research company in Northern Cyprus, with the assistance of 12 trained interviewers assigned to collect data through face to face interview technique.
Analysis
The initial objective of the study was to test the dimensionality of the SERVQUAL instrument in Northern Cyprus health care industry and to fulfill the objective, and the scale was factor analyzed by principal components method with varimax rotation. Cronbach Alpha coefficients of the factors extracted in the analysis were identified to test the reliability of the dimensions. The gap model was later used to assess the service quality provided by both private and public hospitals. To determine the service quality gaps for the hospitals under review, the generally accepted formula (weighted perception-weighted expectation) was put in use; the gaps were then calculated by multiplying the weight assigned to each of the dimensions by expectation scores and the perception scores of each hospital.
Results
Three factors that include; reliability-confidence (α= 0.933), empathy (α= 0.837) and tangibles (α= 0.732) were extracted in the factor analysis using a standard eigenvalue of 1.0.
Discussion
The results of the analysis revealed that reliability-confidence, empathy, and tangibles are the three dimensions of service quality in accordance with the first objective of testing the dimensionality of the SERVQUAL assessment tool. This result does not support the five-factor model of the original SERVQUAL. Objective number two was to assess the service quality provided in public and private hospitals. The gap scores indicate that in all the three dimensions, perceived service falls behind the expectations implying that both public and private hospitals fail to offer the expected service quality to the patients. The finding, therefore, has significant implications, especially for the public hospitals, as the gap scores are much bigger in all the dimensions compared to the private hospitals.
The biggest gap in the public hospitals exists in the reliability-confidence dimension that constitutes from the reliability, assurance and responsiveness issues. The public hospitals depict poor performance in the empathy dimension which is based on the understanding of the specific needs of the patients as well as providing personal attention. The huge gap in the tangibles dimension indicates that the equipment does not look modern and the physical facilities are not visually appealing to the clients. The huge gaps, therefore, signify mismanagement of the public hospitals, and this can be attributed to the non-profit nature of the public hospitals. , and therefore there is no aim of making a profit.
Private hospitals, on the other hand, are perceived as much better service providers than public hospitals. Despite being better service providers, there are still some small gaps in all the dimensions of service quality. The small gaps can be explained by the incentive nature of the private hospitals, as unlike the public hospitals, which are characterized by no profit concerns, inadequate resources as well as the lack of performance management, the private hospitals are profit oriented; and this means that they have to raise funds and use resources efficiently as they are not provided by the government. The private hospitals compete among each other and the other hospitals in the region, and this means that there is still room for improvement in spite of the levels of satisfaction.
The third objective of the study was identifying the dimensions that exert influence patient satisfaction. The logistic regression analysis indicated that the reliability-confidence dimension is significantly effective on satisfaction both in private and public hospitals, and thus an improvement in this dimension would significantly increase in the service quality, thus affecting customer satisfaction. Being empathetic is as well acknowledged to exert influence on customer satisfaction on both public and private hospitals although with a lower intensity. The tangibles dimension have no significant effect on customer satisfaction in the public hospitals’ context but are more or equally influential with empathy in private hospitals.
Recommendations for future studies
Three significant recommendations are provided that include: The SERQUAL scale should be tested on other industries as well as in different parts of the globe. Further investigations should be made for both private and public hospitals to find out the underlying causes of the gaps identified within the organizations and provide high-quality services to their customers. More comprehensive suggestions can be made if price and behavioral intentions are included in future studies.
Reference
Yesilada, F., & Direktör, E. (2010). Health care service quality: A comparison of public and private hospitals. African Journal of business management, 4(6), 962. Retrieved from: https://academicjournals.org/journal/AJBM/article-full-text-pdf/3F06DCA23828
Return-risk
Risk and Return on Investments
Name
Institution
Report to Finance Director of Investment
On
Risk and Return on Investments
Introduction
In the world of investment, risk is termed as opportunity an investment’s in the actual return can be diverse than expectation. Technically, risk statistics measurement is performed through standard deviation. Low risk is linked with the low returns while high risk is connected by high returns. The return/ risk tradeoff termed as balance between lowest risk and highest return.
The relationship between return and risk applied by investors enables them to gain high return by application of low risk. For better management of investment, the investor succeeds in quantification of its direction and relationship (Hampton, 2011). This relationship requires the study impacts of every element. The measurement effect of decrease or increase risk on investment return is determined. The main relationship type of return and risk include, direct relationship between return and risk where the high risk in relation to high return is explained as the high risk taken by investor for a reward (Hampton, 2011). When investor invests one million, the loss risk is estimated as million dollars. If he earns a return of 10%, the return is less through investing of millions where risk loss is millions. The low risk in relationship to low return is seen as the direct relationship in return and risk. If investor reduces investment, he reduces the risk loss now his return reduces.
The second type is negative relationship between return and risk. In this category, high risk amounts to low return. When investor’s investment increases amount of acquiring high return through return increase, he encounters low return due to the nature of project. When increasing investment, no benefit in the project is requiring (Hampton, 2011). In addition, low risk leads to high return where in the projects the low investment amount can result to high return. For instance, Indian government requires money. Due to government requirement of the amount in government and emergency, there is provision of high return in small investment project. This opportunity for money investment will lead to high return for small risk on money loss.
Risk and Return Example
Foreign –exchange investment risk and return: when making an investment in foreign country individual should consider a fact that currency rates of exchange may change the value of asset. Foreign exchange risk employs to almost all financial instruments, which are in currency apart from your local currency (Hampton, 2011). For instance, if a person lives in America and makes investment in Canadian stock using Canadian dollars, whether share value increases, an individual can lose money when Canadian dollar depreciates in association to American dollar. The person can gain money if share value appreciates and Canadian dollar appreciates about American dollar.
Which are more risky bonds or common stocks?
The fact to consider while one is making an investment is that incurs higher returns have higher risks. Safer investments usually have low risk but returns are lower. Different risk levels applying to bonds and common stocks, corporate bonds normally have lowest risk of investment types and offers lower returns (Hampton, 2011). Common stocks present highest risk for investments but have highest potential in returns. Bonds issued through companies represent broadest part of bonds markets compared to US Treasury bonds or securities offered via federal agencies. The risk related with corporate bonds generally depends on financial performance and stability for company issuing bonds, since if company becomes bankrupt it cannot be in position to pay back value of bond or return on an investment. One can assess risk through checking company’s rate of credit via ratings agencies like Moody and Standard & Poor’s.
In considering risk levels, corporate bonds holds lowest risk compared to common stocks kind of investment (Hampton, 2011). This is possible provided an individual chooses right company for which put his investment. The major reason for this was that in occurrence of bankruptcy, those who hold corporate bonds maintain stronger claim on payment than an individual or group holding common stocks. Bonds generally carry lower risk of return for an investment because performance of common stocks is better. Common stocks are associated with highest risk since holders are presented last in payment on occurrence of bankruptcy.
Understanding risk and return
Understanding relationship between return and risk how they are influence by time is the most significant aspects for investing your capital in future. In knowing how they operate and individual’s perception on risk may assist in making investment decisions, which meets your financial requirements and goals best. An investment risk can be termed as the possibility an individual may lose money on an investment or that investments cannot maintain rate with inflation (Hampton, 2011). All investments usually carry risk but a risk level varies depending on kind of investment. Investments perceived to contain higher level in terms of risks have potential to earn an individual higher return on investment for example, growth assets. Investment that earn lower returns if invested like defensive assets, normally carry lower levels of risk. Risk may arise from different angles depending on kinds of investments a person wants to invest. For instance, changes in economies, investments markets, political and social environments may affect different investments in various ways and influence them to either increase or decrease in value.
The common kinds of risk related to investing comprise of financial losses, changes in inflation, currency prices or interest rates and liquidity. Investment return is amount earned or lost on an investment. Return and risk are linked, greater investment opportunity have potential to attain higher returns, but are largely associated with higher risk. Whereas few individuals prefer taking risk, it is normal part in investing. In fact, risk taking is beneficial and of value when undertaking an investment opportunity. As an investor, a person has to accept certain risks in order to attain higher returns. However, it is of significant to ensure that you are not venturing in unnecessary risk. For example, before an individual invest his retirement savings then he requires understanding their risk profile.
The person needs to opt on how comfortable he is with risk and amount taken to attain the returns he wants. For instance could he be comfortable whether value of investment goes up or down over short period. May be he prefers consistent returns to a long term. In understanding how various asset classes run can assist you opt that investment options match their financial goals and risk profile.
References
Hampton, J. J. (2011). The AMA handbook of financial risk management. New York: American Management Association.
Health Care Reforms 2010
Health Care Reforms 2010
(Author’s name)
(Institutional Affiliation)
Introduction
President Obama signed into law his landmark health care bill, one of the most expansive social legislation enacted in history, arguing that it enshrines the central principle that every citizen in the United States should have access to some basic security in regards to health care. The president apparently signed the bill, the Patient Protection and Affordable Care Act to set in motion reforms that millions of Americans have struggled for, hungered to see, and marched for years. In 2010, the president continually expressed his concerns over the necessity of reforms in health insurance calling for the Congress to support the reform. Even after the bill was signed into law, the legislation remains controversial, with numerous states seeking for it to be overturned. Many voters are also against the legislation. The legislation covers a number of reforms in the health care system (Stolberg & Pear, 2010).
One of the reforms has to do with subsidizing insurance and expanding Medicaid. The legislature includes provisions related to health that are supposed to take effect over the coming years, including the expansion of the people eligible for Medicaid making up to 1333 percent of the FPL, subsidizing of premiums of insurance for the poor individuals so that their maximum payments for yearly premiums will be on sliding scale of up to 2 percent of their income, prohibiting denial of claims and coverage based on pre- existing conditions, providing incentives for businesses to benefit the healthcare system with funds, establishing exchanges of health insurance and providing support to research in medicine (Stolberg & Pear, 2010).
The 2010 health care reforms also addressed issues like community rating and guaranteed issue. As of 2014, the legislation will outlaw insurers from denying coverage to applicants who are sicker, or from imposing certain conditions like higher payments or premiums. Expenditures of health care are extremely laden with the most expensive 5 percent of the population making up half of the total spending in health care, while the bottom fifty percent of the spenders only account for three percent, implying that the gains of insurers from avoiding the sick highly outweigh any probable gain from managing their care (Woolhandler & Himmelstein, 1997).
As a result, insurers devoted funds to this avoidance at a direct cost to care management that is effective, which is against the interests of the people insured. Starting from 2014, the legislature will require individuals without health insurance to purchase health insurances approved by the government. Exchanges of government run may present data or information to enable comparison among competing insurers. This requirement is meant to limit the number of individuals without insurance to about 8 percent by 2016. The structure of this insurance premium allegedly shifts more costs to the healthier and younger people, hence the criticism and controversy (Johnson, 2010).
Efficacy of health insurance is also another area covered by the legislature. The act requires that all insurers should cover more costs, indicating that they make use of at least 80 percent of the premiums on quality improvement and medical care, and requiring full coverage for immunizations and screenings, and by outlawing annual and lifetime caps. As a result, a number of insurance schemes in the US have been indicated as inadequate. Other issues are related to the reduction of deficit. Reduction of the deficit is another critical force behind the reforms in healthcare. The legislation was estimated to reduce or cut the deficit by more than 143 billion dollars over the next ten years (Reid, 2010).
Elimination of overpayment in Medicare is also another advantage offered to individuals. Medicare Advantage plans are availed to people by private insurers, offer benefits to them above coverage in Medicare’s Parts A and B, and receive funding for covering these parts. However, unlike this form of coverage, the new legislature it was found out that these plans were overpaying these private insurers. The approximated costs of this overpayment came close to 12 billion dollars each year. The legislation is seeking to change this and remove any window for overpayment to private insurers (Reid, 2010).
This paper is a critical analysis of the 2010 health care reform legislation signed into law by President Obama. The paper will look at some of the institutional barriers interfering with the reforms, some solutions being offered to amend the legislation, the current status of the health policy arena and some of the recommendations the policy makers can assume in the future to improve the legislature.
Background and History
There are numerous provisions of the 2010 health care legislation that have to be met by the end of 2018. These are grouped into categories placed under the years they have to be enacted. For example, there are those provisions that have to be enacted by the end of 2011. Some of these include the following. Insurance companies are prohibited from eliminating people out of their coverage when they fall sick, thereby, ending the rescission practice. In addition to this, by 2011, all limits on lifetime coverage should be removed together with annual limits (Samuelson, 2009). The legislature also provides that young adults be covered by their parents’ cover until they reach the age of 26. Adults who are uninsured with pre- existing conditions are also allowed to obtain health coverage. The legislature requires that insurance companies not deny individuals insurance covers to children less than 19 years of age based on a pre- existing condition (Stolberg & Pear, 2010). These are just some examples of the provisions that insurance companies should meet by the end of 2011.
There are those provisions that are effective as from 2011. Tone is that Medicare provides ten percent as bonus payment to general surgeons and primary care physicians. The legislature requires Medicare to take full responsibility of services from personalized prevention plans for beneficiaries and annual wellness visits. Payments and funds towards insurers offering Medicare advantage are denied. There also those provisions those are to be effected as of 2012. For instance, reforms on payment for physicians are implemented in Medicare to improve central care services and motivate physicians to form organizations that are accountable for caring for individuals to improve efficiency and quality of health care (Reid, 2010).
As of 2013, a national pilot program is created for Medicare on bundling of payments to motivate hospitals, doctor and other providers of health care services to coordinate patient care better. The FICA or the federal insurance contributions act tax is raised from 1.45 percent to about 2.35 percent for those people making more than 200000 dollars and with couples making more than 250000 dollars. This tax is imposed on income from certain investments for the same income group. By 2014, state health coverage exchanges for small businesses and people open. People with income ranging more than 133 percent of the poverty level declared by the federal courts are eligible for the Medicare (Stolberg & Pear, 2010).
Premium caps for maximum payments made out of pocket may be present for those earning incomes more than 400 percent of federal poverty level. Effective 2015, Medicare develops a program for paying physicians aimed at rewarding quality health care rather than quantity of services. Effective of 2018, an excise tax is imposed on high cost plans provided by employers. These are some of the examples of the provisions the 2010 legislature provides for, which are to be imposed by the end of 2018. These provisions affect a number of entities from insurers to individuals to hospitals to doctors to families and couples (Samuelson, 2009).
Solutions currently being proposed with a Pro- Con Analysis
As we already saw in the starting paragraphs, the 2010 health care reform legislature has resulted to a lot of criticism and controversy, with the majority of states criticizing the bill and offering a number of solutions to improve the legislature. Just the same, the bill has also received significant support from a number of states, as well as voters, who remain adamant that the legislature is perfect for correcting the health care inadequacies and unfairness that has been present in the country for decades. One of the main areas of debate that has arose from passing of this bill concerns the effects the bill will have on government spending, taxes and jobs in the US. The supporters of the bill argue that the new law will guarantee millions of jobs for Americans, in addition to making possible for them to access quality and affordable care despite their health and social status. In addition to this, they also argue that the bill will help decrease levels of chronic diseases in US, control increasing spending in health and strengthen the nations damaged health infrastructure. They go on to point that health reforms, investing in them will help the nation achieve the promise previous, and current regimes have made to the people of a higher quality of life (Schweitzer, 2011).
On the other hand, the critics of the bill argue that the reforms depicted by the bill will increase taxes, spending and destroy jobs in the nation. They point out that one of the central concerns of the American people is the increasing costs of health care, and that what the Obama Care bill has done is increase them and not decrease the costs. They point out that the only reason republicans are repealing the legislature is because it will increase taxes, spending and destroy the workforce in the nation. They cited a report by a number of economists that indicated how the bill would increase costs and destroy jobs. They offer a different solution to this legislature by arguing that the congress should do better in replacing the 2010 reform bill with commonsense reforms that will decrease the health care costs and expand access to health care services for Americans (Schweitzer, 2011).
Another issue of conflict between these two camps is on the difference the new legislature is expected to bring in employment and the health care system. The supporters of the bill argue that those who are against the bill are driven by insurance industries who will affected the most by the reforms, and that the basis of their criticism is not lack of results but due to negativism driven by self- interested groups. The critics, on the other hand, point out that they feel that it would be beneficial to repeal the legislature if they are to promote growth of jobs and help restore fiscal balance of the federal government (Schweitzer, 2011).
To them, the legislature will only make matters worse for most Americans who remain unemployed facing a daunting budget. They believe that the bill will act as a threat to American businesses and that it will increase the debt burden of the country. It is their view that the patient protection and affordable care act does not contain real reforms in health care. They instead offer a solution that congress should begin with a clean paper sheet and assimilate initiative that will motivate providers to offer care that is of high quality at lower costs to patients, to reduce the pressures of cost that threaten to bankrupt Medicaid and medicate and give all Americans access to more coverage options (Schweitzer, 2011).
Consideration of Institutional Barriers
It is not just the critics who are a challenge for the survival of this bill. In addition, other challenges and considerations might make the survival of the bill difficult. American institutions are some of the most critical possible barriers for this law. An example of these institutions is the American Supreme Court that has the mandate to block or overturn any law if there is a basis for such an action. Upon the passing of the bill, a number of congressional representatives especially republicans, felt that the decisions made by Obama and his administration, especially on exchange were not constitutional. As it follows, they took the matter to the Supreme Court seeking to repeal the reforms (Millman, 2011).
For some individuals and states trying to repeal and obstruct the act in the Supreme Court, the thought of the intervention by the federal government is enough motivation to start planning for the exchange in case the lawsuit is not successful. In other cases, the consideration of the 2010 health reforms by the Supreme Court is reason enough for them to remain inactive and to paralyze numerous initiatives for health reforms in their states (Millman, 2011). As it follows, the Supreme Court and its possible ruling, which is expected in mid 2012, is one of the major barriers for the implementation of the health care reforms.
The Supreme Court is not the only institution posing a threat to the success of the health reforms; the federal government is also another eminent threat. The state of Kansas is cited to be contemplating to return around 31.5 million dollars to the federal government. The funds were supposed to be used in the state in setting up exchanges of health insurance. The main reason for this return, according to the officials, was the fact that there were doubts concerning the ability of the federal government to pay for the grants in the future. As the officials pointed out, there is considerable uncertainty that the federal government might not be able to meet its already budgeted spending obligations in the future. Kansa is not the only state to turn away from these funding, Oklahoma also refused the same grant in April (McCarthy, 2011). If what these two states are speculating is true, about the incapacity of the government to fund the reforms, then the US will have a problem because the nation is depending on the federal government for financial support to implement most of the reforms in health care. As it follows, the federal government is also another potential barrier to the reforms in health care.
State- based insurance exchanges are other institutions that might act as a barrier for the health care reforms because. According to a number of observers, they are marred with politics. Some republican leaders threaten to refuse to establish exchanges unless the government provides them with more flexibility concerning Medicaid. Lawmakers in several other states implied that they were not inclined to implementing any part of the health law. Other states, however, like Colorado, California and Maryland have come up with legislation to create exchanges. Others are still holding discussions on the issue. If well implemented, proponents assert that exchanges can make it easier for people to buy coverage and maybe even lead to reduced costs because of the increase in competition. However, as experts warn, if poorly implemented, healthy people could be inclined to avoid exchanges, abandoning them to sick people (Appleby, 2011). As it follows, exchanges are other institutions that can affect the implementation of reforms.
Current Status in the Health Policy Arena
It is clear from all conflicts that the health reform bill is not faring well in the health policy arena, mainly because of the limitations it imposes on policymakers, insurers and other interested parties. The bill has come under numerous threats from those individuals who think that the reforms were unconstitutional citing acts in the constitution that do not require the government to impose such stringent reforms on individuals and policies. However, despite these criticisms and opposing groups, the bill has also received considerable support from numerous groups.
Future Policy Alternatives
Though one can come up with a number of alternatives for future developments in the health care reforms, the extent to which these alternatives can go depends only on the successes and failures of the current policy in the coming years, assuming that we will witness a lot of them. However, it is possible that it will be challenging to assess all of these successes and failures before the end of 2014assuming that the Supreme Court does not rule the individual mandate unconstitutional. Additionally, some states such as Vermont have already assumed other alternatives such as the single payer option. This health system will move most of the residents of the state in an insurance program that is financed by the public, and pay doctors, hospitals and other care providers a certain fee to care for the patients. This new alternative will replace the traditional plans of insurance covers currently in use in the state and the traditional reimbursements based on fee for service, providing the state with a different system (Marcy, 2011). Other states can also consider adopting the same alternative to the 2010 health care reforms.
Conclusion
The 2010 health care reforms signed into law by the Obama administration has been the source of numerous debates between numerous republican and democratic states. The both groups give varying reasons as to why the reforms are suitable or unsuitable, with the main differences arising from differing views on the effects of the reforms on the cost of health care, employment and spending. Though the reasoning of both groups could have some essential truth and basis, it is critical that the successes and failures of the reforms be assessed first before voting for against the repealing of the reforms. There are also alternatives to these reforms that states can assimilate to avail cheaper and quality health services to all Americans. The verdict on which direction to take should, however be determined by how the reforms fair or fail in achieving the intended goals.
References
Appleby, J. (2011). A guide to health insurance exchanges. Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/Stories/2011/March/30/exchange-faq.aspx
Johnson, K. (2010). Health premiums may rise 17% for young adults buying own insurance. USA Today.
Marcy, J. (2011). Vermont edges toward single payer health care. Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/Stories/2011/October/02/Vermont-single-payer-health-care.aspx
McCarthy, M. (2011). Brownback: Kansas to return $31.5 million health exchange grant.National Journal Member. Retrieved from http://www.nationaljournal.com/healthcare/brownback-kansas-to-return-31-5-million-health-exchange-grant-20110809
Millman, J. (2011). States squirm over health exchanges. Politico. Retrieved from http://www.politico.com/news/stories/1111/69253.html
Reid, T.R. (2009). The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books.
Samuelson, R. (2009). Robert J. Samuelson on the health bill’s burdens for the young. The Washington Post.
Schweitzer, J. (2011). Are the March 2010 federal health care reforms laws good for AmericaProCon.org. Retrieved from http://healthcarereform.procon.org/view.answers.php?questionID=001526
Stolberg, S. & Pear, R. (2010). Obama signs health care overhaul bill, with a flourish. The New York Times.
Woolhandler, S. & Himmelstein, U. (1997). Costs of care and administration at for-profit and other hospitals in the United States. The New England Journal of Medicine 336 (11): 769–74.