Harvard Changes Employee Health Benefits
The University announced today that under its health-benefits program, Harvard’s nonunionized employees would become responsible for annual deductibles of $250 per individual and $750 per family, and coinsurance equal to 10 percent of costs, for hospital expenses, surgeries, diagnostic testing, and outpatient services, effective January 1, 2015. The individual out-of-pocket maximum for such expenses is $1,500 per year; for families, the ceiling is $4,500 (present limits are $2,000 and $6,000). Above these thresholds—toward which continuing copayments for office visits and prescriptions will count, too—Harvard resumes paying 100 percent of the costs. (For people enrolled in the point-of-service [POS] and preferred-provider-organization [PPO] health plans, rather than health maintenance organizations [HMO], the deductibles for out-of-network care remain $750 per individual and $2,500 as a family maximum, with maximum out-of-pocket costs of $2,500 per individual and $7,500 per family for out-of-network care—but the plan participants will pay a 30 percent coinsurance share for such care, up from the present 20 percent.) As mandated by the Affordable Care Act, preventive care (annual physical and gynecological exams, well-baby care, immunizations, annual screenings for cholesterol, and so on) remains covered at 100 percent.
These changes align University health benefits for nonunionized employees more closely with national norms—but they may well come as a surprise to faculty and staff members accustomed to Harvard’s traditionally full insurance coverage. The changes, signaled in recent financial reports (see “Harvard Financial Context,” below), say something about how University leaders see the institution’s challenges. They also touch on the wider national discussion of healthcare and employee benefits—areas into which faculty experts have delved deeply in search of greater efficiency and enhanced quality (see “Alternative Perspectives,” below).
Separately, the University will offer a so-called “high-deductible health plan” linked to a Health Savings Account, to which beneficiaries can make pretax contributions to fund their future medical costs. As is typical of such plans, it combines lower premiums with higher deductibles, coinsurance, and out-of-pocket maximums. (Such plans are typically considered most suitable for people with a higher tolerance for risk, and the means to absorb larger, less predictable annual costs—and to take advantage of the tax savings available through the pretax funding mechanism. The New York Times on September 2 reported on the increasing adoption of such accounts, and challenges of implementation.)
Most of the affected faculty and staff members are enrolled in HMOs providing healthcare coverage through the Harvard University Group Health Plan or Harvard Pilgrim Health Care, and currently are responsible for copayments for medical office visits and prescriptions. Participants in the HMO plans have been exempt from deductibles and coinsurance until now, as have the POS and PPO subscribers for in-network services. (Harvard insures some 16,000 faculty and staff members, including unionized employees; covered lives total some 32,000 people, including dependents.)
The new health-insurance terms obviously have cross-cutting effects on employees. If they require hospitalization, surgery, or the other affected services during the year, they will now be subjected to the deductible and coinsurance payments, but their premiums will decrease. Harvard obviously expects that: the announcement of the change says, without qualification, “For 2015, monthly premiums in these plans will go down….”—apparently by somewhat less than 3 percent compared to 2014 rates. The medical cost per covered person was increasing about 4 percent—implying that without the changes in the insurance plans, premiums would increase by about that magnitude next year: a swing of 6 percentage points or more compared to the rates the affected employees are now expected to pay in 2015. (Including gains in employment, Harvard’s overall—not per capita—medical costs are increasing at about a 6 percent rate. The recent unveiling of new, more expensive pharmaceutical therapies threatens to increase the cost trend in subsequent years.) Thus, covered employees will enjoy lower withholding for insurance coverage—but because Harvard pays 77 percent of total premiums on average, most of those savings, and avoided cost increases, will accrue to the University. (The Harvard share of premiums varies with insurance plan, income, and family size, ranging from as much as 85 percent down to a percentage in the mid 60s.)
The University’s savings, and employees’ exposure to the new deductible and coinsurance charges, are limited in two important ways.
First, as noted, out-of-pocket maximum exposures per year are reduced—and all copayments for routine services count toward the total (only medical copays count toward such maximums now).
Second, the University is maintaining its unusual commitment to progressivity in health insurance. Premium costs are tiered, with Harvard assuming a higher share of the cost of coverage for employees who earn less than $70,000 per year, a lesser share for those earning $70,000 to $95,000, and a third, lower share for those with incomes above $95,000. It has also offered a program to reimburse copayments above a certain threshold (for in-network office visits and prescription drugs) for employees earning less than $95,000. In 2015, this reimbursement program will extend to the new deductible and coinsurance costs for employees earning less than $95,000, with single limits—adjusted for income and family status—covering all eligible expenses (office visit and prescription copays, deductibles, and coinsurance), rather than the existing, separate limits for the different categories of copayments. Thus, for example, individual beneficiaries with a salary below $70,000 could get reimbursement for combined costs exceeding $900 ($2,250 for families); those earning $70,000 to $95,000 are eligible for reimbursement for combined costs exceeding $1,250 for individuals and $3,125 for families.
The University’s statement makes clear the motivation for the changes. In an announcement e-mailed to affected faculty and staff members, Marilyn Hausammann, vice president for human resources, wrote:
Harvard, like all employers, continues to grapple with health care costs that have increased at a pace well over the rate of inflation for many years. More generally, benefits have grown to consume 12 percent of the University’s budget (from 8 percent) over the past decade.
Though we have taken a number of steps to moderate health cost increases—and continuously review our benefits to ensure that they remain affordable for faculty and staff, sustainable for Harvard in the long term, comprehensive, and highly competitive—we need to do more to curb cost growth and improve incentives for health plan participants.
As the accompanying preview of benefits changes put it, should growth in benefits costs continue at the recent pace, Harvard would find it “difficult to make the investments necessary to remain preeminent as an institution, to maintain the quality and affordability of our benefits, and to provide competitive salaries.” Accordingly, the resulting “changes in the way health care costs are shared between Harvard and its faculty and staff” aim to “curb cost growth, and just as important, to improve our incentives for becoming better consumers of health care so that more significant changes can be averted in the longer term.”
The context for such actions had been established previously. In their message in the annual financial reports for 2012 and 2013, then-University treasurer James F. Rothenberg and vice president for finance Daniel S. Shore, Harvard’s chief financial officer, singled out employee-benefit costs for special attention. In fiscal year 2012, they wrote, “benefits expense has more than doubled in the past decade to $476 million.” They termed that increase “unsupportable…relative to actual and expected growth in the University’s revenue” and declared that “with those costs continuing to increase at unsustainable rates, Harvard—like its peers and indeed like most other businesses—cannot simply continue with the status quo.” As noted then:
Although healthcare is the largest component of employee benefits, several factors appear to contribute to rising expenses. The trend factor—utilization and the costs of medical care—is increasing, although apparently not at the double-digit rates of a decade ago. The workforce is expanding, and salaries and wages are increasing, making for higher payroll taxes. Interest rates have fallen, making it much more expensive to pay for unfunded pension and retiree healthcare costs.
In the near term, the University is addressing those costs largely by effecting changes in healthcare benefits…and by increasing the share of premiums that higher-paid employees will bear in calendar 2013. (Nonunion employees earning less than $70,000 have paid about 15 percent of the cost of health insurance; those earning $70,000 to $95,000 have paid about 20 percent; and those earning more than $95,000 have paid about 25 percent. As of January 1, the University is increasing the share of costs for those two upper tiers by about 2 to 3 percentage points.)
Unionized employees have resisted such changes, and the issue has been the subject of protracted, difficult negotiations in recent years. One implication of the new health-benefit provision just announced is that the fringe-benefit rate applied to unionized employees is now much higher than that for “exempt” faculty and staff members—a gap in the high teens of percentage points.
[Updated 9-3-2014 at 4:25 p.m. to incorporate comments from the Harvard Union of Clerical and Technical Workers:
In a quick reaction to the University announcement, Bill Jaeger, director of the Harvard Union of Clerical and Technical Workers (and a past member of the University Benefits Committee, described below), noted, “We’re not yet directly affected. Our members are not subject to these changes—although we expect the University will ask us to negotiate about the possibility of their application to our members.” In general, he said, “This is a very different kind of a health plan. It’s a radical change from our perspective,” characterizing the new provisions as “going in the wrong direction. They aren’t going to do anything to solve the real problems of healthcare costs. It’s a short-term step in the wrong direction that shifts costs on to employees, and from healthier employees to sicker people”—older people and those with chronic illnesses.
Absent access to Harvard claim data, Jaeger continued, “It’s hard to know how sharp the effect will be. But employees will pay a bigger share of the health bill, and the employer less.” In light of recent data documenting slower growth in health costs nationwide during the past five years, he asked, “Why now?” He maintained that the University’s announcement shows it is “jumping on a bandwagon—but it’s not clear whether that bandwagon is headed in an appropriate direction.” ]
In fiscal 2013, total employee-benefit costs increased 6 percent (in line with fiscal 2012), to $507 million. (Per-capita increases were lower, reflecting the roughly 2 percent average annual workforce growth in recent years.) Discussing financial disciplines in that year’s report, Rothenberg and Shore wrote that some changes, “such as reducing the growth rate of our benefits costs, can be more difficult since they often are experienced at a more personal level. Yet these changes are inevitable and will allow us to protect the integrity of the high-quality teaching and research that has allowed Harvard to lead throughout the centuries.”
And indeed, as reported, Harvard put into place changes in retiree health benefits, effective January 1, 2014, affecting nonunion employees with more than five years to eligibility for coverage. Those changes reduce the University’s share of the premium cost for the coverage, and to varying degrees, increase the number of years of service to attain the maximum subsidy. For employees hired after that date, the minimum years of service and the age to qualify for coverage both increase; the number of years of service to attain the maximum subsidy rises (by a decade); and the University will cap the growth in its contribution to insurance premiums at 3 percent annually from 2020. In the aggregate, these represent potentially large reductions in Harvard’s future liability for retiree healthcare.
As of this writing, figures had not been made available from the University for its actual spending on healthcare, within the half-billion-dollar employee-benefits line in the fiscal year 2013 annual financial report (including health, pension costs, and other expenses for active and retired workers), nor for the estimated dollar savings anticipated in 2015 from the new health provisions.
Harvard Insurance Context
“Harvard’s goal is really first and foremost providing a compensation policy that is attractive to the employees it wants to attract,” said Joseph P. Newhouse, MacArthur professor of health policy and management at Harvard Medical School (HMS), where he directs the division of health policy research and education. “Like any major employer, it looks at its benefits relative to the labor market—what it considers its peer institutions,” continued Newhouse, who also holds appointments in the Harvard School of Public Health (HSPH), Harvard Kennedy School (HKS), and Faculty of Arts and Sciences (FAS). As a general matter, he noted, the University “compares rather favorably to those institutions on health insurance”—which has implications for the composition of compensation as a whole, including salaries and wages, and other benefits such as pension and retirement plans.
Like many academic institutions, “We have a very generous health-insurance plan, but even more so” at Harvard, said Katherine Swartz, professor of health policy and management at HSPH. In modifying its health insurance, she said (during a conversation preceding the release of details concerning the new deductible and coinsurance schedules), Harvard “is not doing anything radical at all.” As she wrote in “Cost-sharing: effects on spending and outcomes,” a survey for the Robert Wood Johnson Foundation published in December 2010, “A majority of people with [employer-sponsored insurance] face a deductible before most of the covered medical services are paid for in part by the plans”—and at that time, 16 percent of covered workers paid some coinsurance rate. (According to the Kaiser Family Foundation’s 2013 Employer Health Benefits Survey, 78 percent of covered workers were enrolled in plans with a general annual deductible that year—although 59 percent of those in HMOs were not—and 61 percent of covered workers had coinsurance requirements for hospitalizations.)
Newhouse’s and Swartz’s assessments carry dual weight in the context of Harvard’s health-insurance decisions, given their scholarly expertise and their membership on the University Benefits Committee (UBC); Hausammann wrote in the preview of benefits changes that the actions had been taken “after consultation” with the committee. Its 15 members include health and public-policy scholars, financial and human-resources administrators (among them Shore and Hausammann), and others from across the University, serving in an advisory capacity to Provost Alan Garber, himself a scholarly expert on the cost-effectiveness of various healthcare procedures and policies.
Newhouse directed the 1970s RAND Health Insurance Experiment, the foundational research that proved, as he said, “people who had more cost-sharing did use fewer [health] services”—that price influences people’s behavior when seeking medical care. In the experimental cohort, which excluded the elderly, Newhouse said, there were “no adverse effects of using less” care among average members of the insured population, with the important exceptions of those in the lowest 20 percent of the income distribution and people suffering chronic illness—whose decisions on occasion to forgo healthcare services as a result of higher costs imposed a health penalty. Swartz’s 2010 overview is a particularly comprehensive review of what is known about the effects of such cost-sharing in the current healthcare context, with very different insurance designs and even therapies (from powerful pharmaceuticals to such technologies as MRI scans) from those in place during the RAND investigation.
As both professors point out, Harvard must offer health insurance in an exceptionally expensive market. “Massachusetts has one of the highest medical costs per person of any state,” said Newhouse, “and much of that is in eastern Massachusetts.” Data compiled by the Centers for Medicare and Medicaid Services show that Massachusetts costs one-third or more above the national average (a level exceeded or approached only by the District of Columbia and California). The hospital portion of those costs is more than 40 percent above the national average (and presumably even more skewed if one considers only metropolitan Boston).
The RAND finding that average people suffered no adverse health effects from curbing consumption when their costs for medical services rise is of course tantalizing to employers who provide, and have traditionally paid for most of, health insurance. But there is also significant concern that, as Swartz writes, “Health plans with high deductibles and uniformly applied co-payments or coinsurance rates are often referred to as ‘blunt instruments’ for reducing unnecessary health care expenditures because evidence is mounting that people reduce both essential and nonessential care” (emphases added). Hence the importance of teasing out those effects—on health outcomes, and on hoped-for savings in healthcare spending overall—in her thorough review of a vast literature on such tools. Among her salient findings:
The declines in use of care and spending documented in the RAND study came from lessened patient-initiated services (for example, making an appointment to see a physician), “rather than from lower intensity of services provided once a person was seen by a health care provider.” That is, once a patient is in the care system, cost-sharing through deductibles and coinsurance was not potent in controlling healthcare costs overall.
That matters because most healthcare spending “is for a small share of the population.” In a given year, “Half of all Americans account for only 3 percent of all health care spending. While increased cost-sharing may cause them to lower their use of health care, their reductions will not significantly affect total spending or slow the growth in national spending. At the same time, people in the top 5 percent of health care expenditures account for about half of all spending—and they are generally very sick people. Once they begin to seek medical advice and care, their subsequent decisions about their options for medical treatment are generally unaffected by cost-sharing.” Given this distribution of costs, higher deductibles and coinsurance certainly redistribute monies among employers and employees, but “We do not know if increased patient cost-sharing would reduce the growth in total national health care spending.”
“Increased cost-sharing disproportionately shifts financial risk to the very sick,” given the intensity of their use of health services.
In this context—a very high-cost market for medical services, escalating overall benefits costs for the University, and concern about the incidence of cost-sharing measures such as the newly introduced deductible and coinsurance provisions—Swartz said that as it evaluated changes, the UBC was very careful to strike a balance. In advising on the changes, she said, “We faced some really hard choices that we’ve tried our best to be fair about.”
The new deductible and coinsurance levels are not especially high by national standards, according to the Kaiser Foundation data. Lowering the maximum out-of-pocket limits lessens the risk of unexpected, shock costs for families. And the out-of-pocket reimbursement mechanism, with its inclusion of all beneficiary payments, appears to be an innovative procedure that, when combined with the University’s progressive schedule for employee premium payments, has the effect of further protecting those for whom the new costs could be disproportionate.
In the end, the changes are meant to save the University money—an objective with which Swartz and several of her health-economist colleagues are sympathetic—while maintaining a full-featured benefits program.
Not everyone embraces the approach of sharing of health costs through deductibles and coinsurance, on several grounds.
The economic critiques. As Joseph Newhouse—a proponent of cost-sharing—noted, the basic economic effect is clear: “People who had more cost-sharing did use fewer services”: for employed, healthy, under-65 adults, on the order of one to two fewer office visits yearly, and a 10 percent to 20 percent reduction in hospitalization. But the reduction in utilization “seems to affect both efficacious and medically inefficacious services.” (That accounts for the prevailing hypothesis on why using less care did not result in worse health outcomes for the generally well population: reductions in useful care were offset by reductions in care that was harmful or counterproductive. That conclusion obviously does not apply to someone with a chronic condition like diabetes or heart disease cutting back on proven pharmaceuticals.) Or as Swartz wrote in her recent survey, “[M]ost people do not distinguish between health care services or prescription drugs that are essential and those that are not essential.” Hence the bluntness of cost-sharing, and the need to shape it carefully—particularly in earlier eras, when preventive services were not protected from such instruments, as they are now.
“Behavioral Hazard in Health Insurance,” a recent National Bureau of Economic Research paper by professor of health economics Katherine Baicker (HSPH), professor of economics Sendhil Mullainathan (FAS), and Dartmouth economist Joshua Schwartzstein in fact makes the case more generally:
Attention matters: choice of care may depend on the salience of symptoms, which is particularly problematic because many severe diseases have few salient symptoms. Timing matters: people may overweigh the immediate costs of care, such as co-pays and hassle-costs of setting up appointments or filling prescriptions. Memory matters: people may simply forget to take their medications or refill their prescriptions. Beliefs matter: people may have false beliefs and poor learning mechanisms about the efficacy of different treatments.
Accordingly, alongside the “moral hazard” that insured people will over-consume health services for which they are charged too little (the rationale for copayments and so on), they model the behavioral hazards—mistakes or biases—that cause them to underuse high-value care.
As Swartz noted, because most health services are consumed by very ill people, whose care is determined primarily by providers, and only a very limited share of services is consumed by a large part of the population, cost savings need to come from the remaining people who, presumably, need medical care upon occasion. But can they then shop effectively for such services?
Nancy Turnbull—senior lecturer on health policy and associate dean for professional education at HSPH, and a former member of the UBC—argues that coinsurance is “very problematic” because “you can’t know the price of any service when you’re getting it.” Most providers don’t provide price information, and most people, at the time of need, are in no position, or frame of mind, to try to dig it out and insist on getting the best deal. For a relatively simple decision—choosing a generic drug versus a branded prescription at a higher copayment—Turnbull says that most consumers can make the right decision (particularly because the prescriptions have been vetted for them). But for more complicated services where prices are not known, she rejects the idea that making “more responsible consumers” by exposing them to part of the costs and reducing “our rapacious use of medical care” is workable.
Three possible courses of action. Most employers, of course, have not hesitated to use cost-sharing to control their health outlays, no matter these analytical concerns. How might employers who are so inclined offer insurance benefits designed to overcome some of these problems—protecting their own budgets while promoting better care and cost savings (rather than just the reallocating expenditures via cost-sharing)? That in fact is a field where Harvard health scholars have a great deal of at least theoretical expertise.
•Better service delivery. At the simplest level, Swartz laments limits on doctors’ office hours that push consumers to emergency rooms during evenings and on weekends. Some physician practices, she notes, do staff such services, but the need for lower-cost, urgent-care services around the clock is pressing.
•Value-based insurance design. “I would not discard patient cost-sharing as a set of tools just because it doesn’t always work as we want it to,” said Baicker. “Well-designed cost-sharing can improve healthcare outcomes” by reducing use of low-value services. The clearest example of such effective design is the tiered copayments for prescriptions, with generics costing users much less than the branded equivalent drug. Such value-based insurance design, much studied by the Medical School’s Michael E. Chernew, Schaeffer professor of health care policy, who chairs the UBC, aims to apply such disciplines much more broadly. The theory is that experts can determine whether an intervention—surgery for back pain, stenting an artery—is effective in various circumstances, and can apply tiered pricing accordingly. The discipline is not perfected, Baicker noted (nor are patients or providers, or even regulators like Medicare authorities, always willing to do what the cost-effectiveness studies show: consumers who become ill want the best available care, naturally). But it holds great interest, among health researchers at least, given their findings that many procedures are not warranted for many prospective patients. Better information, designed into insurance plans, and greater patient sensitivity to prices, theoretically hold great promise for effecting financial savings and enhanced health.
•Tiered networks and insurance. Providers of medical service vary in price and effectiveness. The literature abounds with examples, from the $400 MRI in a freestanding clinic versus the $1,000 version in a hospital setting, to the cases documented in Elizabeth Rosenthal’s continuing New York Times series, “Paying Till It Hurts.” Baicker noted that with sufficient information and will, providers could be sorted out into those that provide lower and higher value for the care dollars they receive. The policies offered through exchanges under the Affordable Care Act aim to distinguish providers this way, she observed, and in theory that should induce providers to compete to be in the preferred networks. Insurers know how to “narrow” their networks of providers based on cost and at least rudimentary measures of effectiveness—and Medicare is making more information available on doctors, to complement the data it has long published on hospitals.
If expert analyses can be made of cost and value—of effectiveness—then that information could be signaled to consumers (who may lack the capacity, individually, to make such studies) by offering them different tiers of insurance plans, initially on the basis of provider’s prices.
Eckstein professor of applied economics David M. Cutler—a former member of the UBC, and now a member of the Massachusetts Health Policy Commission (an independent agency charged with developing policies to reduce the growth of healthcare costs and improve the quality of care)—has written extensively about this mechanism. Last December, in the New England Journal of Medicine, he and two coauthors—writing about the deceleration in the growth of U.S. healthcare spending—observed that patients could be rewarded “for choosing providers and organizational arrangements…that are associated with better outcomes and lower costs of care. Tiered networks constitute an early version of this approach to consumer engagement.” A month earlier, in “Hospitals, Market Share, and Consolidation,” published in the Journal of the American Medical Association, Cutler and Fiona Scott Morton (of the Yale School of Management) wrote of tertiary-care institutions, “[F]lagship academic medical centers offering perceived higher quality care often wield enormous market power.” They cited a report by the Massachusetts attorney general finding wide differences in pricing but “no correlation between hospital price and quality” in Harvard’s market area. Cutler and Morton suggest insurance programs with differential cost-sharing: “routine surgery could involve higher consumer cost sharing if provided at the dominant health system in a market than in a less expensive one”—a tiered network.
At a higher level, Cutler and Morton argued, the incentives for care systems themselves could be changed to encourage cost savings—the aim of nascent experiments with “accountable-care organizations,” where providers share the savings, or the excess costs, depending on how they perform relative to agreed-upon budgets for an insured population each year. Finally, states could experiment with overall expenditure restraints.
Both of the latter measures are being pursued in Massachusetts—with the eastern part of the state the epicenter of such work, according to Newhouse. It is in this market that Harvard-affiliated academic medical centers—world-renowned for the quality of their care, but also considered among the highest-price providers—loom particularly large.
An ethical perspective. Critics like Turnbull strongly favor a health system with providers competing to offer insured health services for agreed-upon prices (the accountable-care model), and with consumers offered various levels of service for differing insurance premiums. That way, she said, consumers could make reasonably informed decisions about what they were buying, at what price, before they became ill or in urgent need of care—when they are least prepared to shop around. (Of course, such differentiation could result in the unattractive prospect that higher-paid employees opt for the “richer” network and lower-paid staff members for the seemingly discounted one—a prospect most employers, and employees, seem uneager to embrace, at least so far.)
More broadly, Turnbull said, the move toward cost-sharing at the individual consumer level—particularly through coinsurance—“means that people who use more medical services are disadvantaged relative to those who don’t.” Turnbull noted that the move toward deductibles and coinsurance is “part of nationwide pressures that all employers are feeling”—a trend that is further along elsewhere than in Massachusetts, and among other employers than Harvard. Still, she views steps toward cost-sharing as in effect undoing some of what insurance is intended to do: moving from a system of sharing risk, she said, toward one where, “more and more, you’re on your own.”
Moving Harvard A Bit Closer to the Rest of the World
The changes Harvard is introducing today are relatively modest in the context of contemporary benefits design, but they represent new circumstances for a workforce that has enjoyed its fringe-benefits package. (In fact, the University’s plan is so competitively attractive that it appears to be enrolling people who have competing plans available through their spouses’ workplaces—a status no employer seeks, given the costs.)
The University has clearly determined to change the price signals faculty and staff members receive (and to pursue negotiations about such changes with its unionized workforce)—but also, at least initially, to buffer the effects and to lessen them for those who receive lower salaries. In striking the balance among its budgets and health benefits, it has taken pains not to impose enormous risk on any individual or family—a point Newhouse emphasized as fundamental in any program of “shifting financial risks,” particularly where shock losses from a medical crisis or chronic illnesses are a factor. It has also had to balance those factors against the interests of its affiliated, research-oriented, teaching hospitals—which are under varying financial pressures, but with varying levels of market strength and political clout, of their own.
The unfolding experiments in the Massachusetts healthcare marketplace will have an important influence on what further changes, if any, Harvard feels compelled to introduce in the years to come. The interplay among University-affiliated actors involved in delivering medical care, consuming it, balancing budgets, and assessing the effectiveness and efficiency of health policies and services might well become an enlightening conversation, not only within the University community but far beyond.