Consumer-directed Health Plans Research Articles

Paying patients to use lower-priced providers.

Many employers have introduced rewards programs as a new benefit design in which employees are paid $25-$500 if they receive care from lower-priced providers. Our goal was to assess the impact of the rewards program on procedure prices and choice of provider and how these outcomes vary by length of exposure to the program and patient population. A total of 87 employers from across the nation with 563,000 employees and dependents who have introduced the rewards program in 2017 and 2018. Difference-in-difference analysis comparing changes in average prices and market share of lower-priced providers among employers who introduced the reward program to those that did not. We used claims data for 3.9 million enrollees of a large health plan. Introduction of the program was associated with a 1.3% reduction in prices during the first year and a 3.7% reduction in the second year of access. Use of the program and price reductions are concentrated among magnetic resonance imaging (MRI) services, for which 30% of patients engaged with the program, 5.6% of patients received an incentive payment in the first year, and 7.8% received an incentive payment in the second year. MRI prices were 3.7% and 6.5% lower in the first and second years, respectively. We did not observe differential impacts related to enrollment in a consumer-directed health plan or the degree of market-level price variation. We also did not observe a change in utilization. The introduction of financial incentives to reward patients from receiving care from lower-priced providers is associated with modest price reductions, and savings are concentrated among MRI services.

Financial Risk for COVID-19–like Respiratory Hospitalizations in Consumer-Directed Health Plans

IntroductionThis study aims to quantify out-of-pocket spending associated with respiratory hospitalizations for conditions similar to those caused by coronavirus disease 2019 and to compare out-of-pocket spending differences among those enrolled in consumer-directed health plans and in traditional, low-deductible plans.MethodsThis study used deidentified administrative claims from the OptumLabs Data Warehouse (January 1, 2016–August 31, 2019) to identify patients with a respiratory hospitalization. It compared unadjusted out-of-pocket spending among consumer-directed health plan enrollees with that among traditional plan enrollees using difference of mean significance tests and repeated the analysis separately by age category and calendar year quarter. These data were collected on a rolling basis by OptumLabs and were analyzed in March 2020.ResultsCommercially insured consumer-directed health plan enrollees had significantly higher out-of-pocket spending than traditional plan enrollees, and these differences were largest among younger populations. The largest difference in out-of-pocket spending occurred during the first half of the year.ConclusionsConsumer-directed health plan enrollees may experience differential financial burden from a hospitalization related to coronavirus disease 2019. Although some insurers are waiving cost-sharing payments for coronavirus disease 2019 treatment, self-insured employers remain exempt. As of now, policy responses may be insufficient to reduce the financial burden on consumer-directed health plans enrollees with respiratory hospitalizations related to coronavirus disease 2019.

Reimbursement of ambulatory blood pressure monitoring in the US commercial insurance marketplace.

Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for confirming hypertension diagnosis and ongoing hypertension monitoring. However, reimbursement in the United States is variable and low compared with other advanced health care systems. We examined the reimbursement of ABPM and factors associated with successful reimbursement. A retrospective analysis of IBM MarketScan® commercial claims database was conducted for patients ≥18years with ≥1 ABPM claim from January 2012 to December 2016. The date of first the ABPM claim was used as the index date. Per-beneficiary ABPM episode reimbursements were calculated by aggregating all ABPM-related reimbursements within a 30-day post-index window, considered as an ABPM episode. Multivariable logistic regression was used to identify predictors of successful reimbursement. Of 20875 beneficiaries with ABPM claims, 16920 (81.0%) were reimbursed. The median reimbursement per beneficiary for an ABPM episode was $89 (Inter Quartile Range [IQR], $62, $132), driven primarily by reimbursement for the full procedure (median, $86; IQR, $66, $110). Comparing benefit plan types, consumer-directed health plans provided the highest median reimbursement ($96; IQR, $61, $175). Successful reimbursement was associated with female patient sex (adjusted OR [aOR], 1.20; 95% CI, 1.11-1.28), having a health maintenance organization (aOR 2.11; 95% CI, 1.82-2.43) or point of service (aOR 2.08; 95% CI, 1.74-2.49) as benefit plan types, claim filing by a specialist (aOR 1.26; 95% CI, 1.14-1.40) and services provided at an outpatient hospital (aOR 1.17; 95% CI, 1.01-1.35). Among commercially insured Americans, our data suggest significant variability in successful reimbursement. Accordingly, more uniform criteria for ABPM reimbursement may facilitate greater use of guideline-recommended monitoring.

The Role of Commercial Health Insurance Characteristics in Bariatric Surgery Utilization.

The aim of this study was to understand relationships among insurance plan type, out-of-pocket cost sharing, and the utilization of bariatric surgery among commercially insured patients. Only 1% of eligible persons undergo bariatric operations, and this underutilization is often attributed to lack of insurance coverage. But even among the insured, underinsurance is now recognized as a major barrier to accessing medical care. The relationships among commercial insurance design, out-of-pocket cost sharing, and elective surgery utilization, particularly in bariatrics, are not well understood. Retrospective review of 73,002 commercially insured members of the IBM MarketScan commercial claims database who underwent bariatric surgery from 2014 to 2017. The exposure variables were insurance plan type and out-of-pocket cost sharing. The outcome was utilization of bariatric surgery. We also examined seasonal trends in bariatric surgery utilization stratified by average levels of cost sharing. Utilization of bariatric surgery was higher in plans with lower cost sharing, such as PPOs (20 operations/100,000 enrollees) than in HDHPs (high-deductible health plans, 12.1 operations/100,000 enrollees). Overall, every $1000 increase in cost sharing was associated with 5 fewer bariatric operations per 100,000 insured lives; this association was strongest in plans with high cost sharing (high-deductible and consumer-directed health plans). Members of all plan types had higher surgical utilization in quarter 4 relative to quarter 1 of each year; these seasonal variations were also most pronounced in plans with high cost sharing. Insurance plan types with higher cost sharing have lower utilization of bariatric surgery. Underinsurance may represent a newly identified barrier to surgical care that should be addressed by advocates and policymakers.

Ten-Year Trends in Consumer-Directed Health Plan Enrollment and Out-of-Pocket Costs among Commercially Insured Members with Diabetes

Background: Diabetes is a major cause of morbidity and mortality and a driver of escalating health care costs in the U.S. In attempts to reduce costs, U.S. employers are increasingly offering consumer-directed health plans (CDHPs) that include Health Savings Accounts (HSA) or Health Reimbursement Arrangements (HRA) and high annual deductibles. Recent research has found that CDHPs are associated with concerning impacts on diabetes patients, but growth in CDHP enrollment and their out-of-pocket (OOP) cost trends in this vulnerable population are unknown. Methods: We used a time series design to assess 2005-2014 annual trends among ∼70 million unique members of all ages insured by a large national commercial insurer from 2005-2014. We analyzed mutually exclusive populations of interest, identified by ACG, comprising: (1) diabetes mellitus with no cardiovascular disease (DM), (2) diabetes with co-morbid cardiovascular disease (DM+CVD), and (3) “healthy” (i.e., ACG score <=1). We used linear models, t-tests and chi-square tests to assess (a) CDHP and non-CDHP prevalence and (b) total annual OOP costs in 2014 dollars. Results: CDHP prevalence among DM members increased by 2.5% per year (p<0.001), from 1.3% in 20to 23.2% in 2014. DM+CVD members had a similar increase. In 2014, 19.5% of DM+CVD members and 28.7% of healthier members were in CDHPs (p<0.001 for both compared to DM). Annual OOP costs for non-CDHP members were significantly lower than for CDHP members throughout the study period. For example, in 2014, CDHP DM members had average OOP costs of $2103.62 compared to $1379.87 for non-CDHP DM members (p<0.001). Conclusions: CDHP enrollment has increased markedly over the last 10 years among members with and without diabetes. However, diabetes members were less likely than healthier members to be in CDHPs, particularly if they had co-morbid CVD. Among diabetes patients, OOP costs were significantly higher for CDHP than non-CDHP members. Disclosure L.F. Garabedian: Other Relationship; Self; Harvard Pilgrim Health Care. D. Ross-Degnan: None. F. Zhang: None. M.X. Callahan: None. R. LeCates: None. J. Wallace: None. S.B. Soumerai: None. J.F. Wharam: None.

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

Ensuring America's Health: The Public Creation of the Corporate Health Care SystemRemaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers

The long term effects of “Consumer-Directed” health plans on preventive care use

“Consumer-Directed” Health Plans (CDHPs), those with high deductibles and personal medical accounts, have been shown to reduce health care spending. The impact of CDHPs on preventive care is unclear. On the one hand CDHPs might increase use of preventive care as such care is exempt from the deductible. However, CDHPs also decrease visits to physicians which might results in less screening. Prior research has found conflicting results. In this study, using data from 37 employers we examine the effects of CDHPs on the use of cancer screenings up to three years after the initial CDHP offering with ITT and LATE approaches. Being offered a CDHP or enrolling in a CDHP had little or no effect on cancer screening rates but individuals increase screenings prior to enrolling in a CDHP. Our findings suggest the importance of examining CDHP effects on periodic care over the longer-term and carefully controlling for anticipatory stockpiling.

Small Decline In Low-Value Back Imaging Associated With The 'Choosing Wisely' Campaign, 2012-14.

Choosing Wisely was launched by the American Board of Internal Medicine in April2012 as a patient- and clinician-targeted campaign to reduce potentially unnecessary "low-value" medical services. The campaign's impact on low- and high-value care beyond its first year is unknown; furthermore, it is unknown whether some patients such as members of consumer-directed health plans and people residing in different US regions have responded more than others. To evaluate the impact of Choosing Wisely, we used commercial insurance claims to track changes in the use of low-value imaging (x-ray, computed tomography, and magnetic resonance imaging) for back pain before and after the campaign began, a period running from 2010 to 2014. We selected back pain imaging because it is a prominent target of Choosing Wisely, which considers it low value except in a minority of cases, because of its relatively high out-of-pocket expense, and the large volume of low back pain visits nationally. We found only a 4percent relative reduction in low-value back imaging 2.5 years after the start of the campaign and some differences in regional trends, but no differences associated with enrollment in consumer-directed health plans. Our findings highlight the ongoing challenge of reducing unnecessary medical care, even when patients have "skin in the game" under consumer-directed health plans.

Association Between Employee Earnings and Consumer-Directed Health Plan Choices

INTRODUCTIONThis study explores the relationship between employee earnings and choice of a consumer-directed health plan (CDI IP) verses a managed care plan in an employer-sponsored insurance (ESI) program. The increased variation in healthcare insurance plan designs over the past decade has led to a greater need to understand the impact of consumer choice with respect to health insurance plans. CDHPs are associated with plan designs that incorporate high deductibles and greater cost sharing. Researchers have consistently found that employee earnings are positively associated with CDHP enrollment (Barry, Cullen, Galusha, Slade, & Busch, 2008; Buntin et al., 2006; Cohen & Martinez, 2009; Dicken, 2006; lx) Sasso, Rice, Gabel, & Whitmore, 2004; Parente, Feldman, & Christianson, 2004a, 2004b, 2008; Tollen, Ross, & Poor, 2004). However, it is unclear if variations in CDHP choice are discernable at all levels of employee earnings.CDHPs emerged in the early 2000s as an alternative healthcare insurance plan design intended to slow the persistent cost increases of ESI, which have nearly doubled since the late 1990s (Claxton et al., 2014). From 2006 to 2014, CDHP enrollment for ESI plans has grown from 4% to 20%, with 27% of employers offering at least one CDHP plan (Kaiser Family Foundation, 2013). Through high deductibles and greater upfront cost sharing by enrollees, CDHPs encourage consumer engagement in healthcare decision making to presumably lower discretionary healthcare use and facilitate better healthcare choices, thus reducing ESI costs or slowing their rate of growth.Health Reimbursement Arrangements and Health Savings Account-Eligible PlansHealth reimbursement arrangements (I IRAs) and health savings account (1ISA)-eligible high-deductible plans have become the two primary CDHP models. From the perspective of enrollees, HRA designs are similar to HSAs relative to the financing arrangement or savings account, but unlike I IS As, I IRA funds are not owned by employees and do not require coupling with a highdeductible plan (Bloche, 2006).HRAs emerged in 2001 and were modeled on the 1996 medical savings account (MSA) pilot program that was part of the Health Insurance Portability and Accountability Act (Parente et al., 2008). Although I IRAs can be offered as a stand-alone, defined-contribution vehicle, they usually are coupled with a high-deductible plan. Employers finance the HRA to offset enrollee out-of-pocket costs; however, a gap or donut hole in coverage remains. The donut-hole phase-the employee's high-deductible period-takes place when I IRA funds are exhausted and before plan indemnity begins.HSAs were established as part of Medicare legislation passed in 2003 (Parente et al., 2008). HSAs introduced employee funding and ownership of the medical spending account, which is portable, may contain investment characteristics, and allows greater employee control over the level of funding to subsidize healthcare costs. The level of employee funding, and annual accrual of such funds, determines enrollees' exposure to out-ofpocket costs during the high-deductible period.Association Between CDHPs and Enrollee EarningsResearch findings show a positive association between CDHPs and enrollee earnings, which may suggest favorable selection (Barry et al., 2008; Buntin et al., 2006; Cohen & Martinez, 2009; Dicken, 2006; Id Sasso et al., 2004; Parente et al., 2004a, 2004b, 2008; Tollen et al., 2004). Individuals in higher socioeconomic groups are generally healthier and require fewer healthcare services than do those in lower socioeconomic groups (Bloche, 2007; Hughes-Cromwick, Root, & Reohrig, 2007; Marquis et al., 2006). Alternatively, households with higher earnings may have a higher risk tolerance or premium cost elasticity, meaning they are less willing to pay higher premiums for lower cost-sharing risk (Callan & Johnson, 2002; Parente et al. …

Out-of-Pocket Spending for Hospitalizations Among Nonelderly Adults.

Patients' out-of-pocket spending for major health care expenses, such as inpatient care, may result in substantial financial distress. Limited contemporary data exist on out-of-pocket spending among nonelderly adults. To evaluate out-of-pocket spending associated with hospitalizations and to assess how this spending varied over time and by patient characteristics, region, and type of insurance. A retrospective analysis of medical claims for 7.3 million hospitalizations using 2009-2013 data from Aetna, UnitedHealthcare, and Humana insurance companies representing approximately 50 million members was performed. Out-of-pocket spending was evaluated by age, sex, type of insurance, region, and principal diagnosis or procedure for hospitalized adults aged 18 to 64 years who were enrolled in employer-sponsored and individual-market health insurance plans from January 1, 2009, to December 31, 2013. The study was conducted between July 1, 2015, and March 1, 2016. Primary outcomes were total out-of-pocket spending and spending attributed to deductibles, copayments, and coinsurance for all hospitalizations. Other outcomes included out-of-pocket spending associated with 7 commonly occurring inpatient diagnoses and procedures: acute myocardial infarction, live birth, pneumonia, appendicitis, coronary artery bypass graft, total knee arthroplasty, and spinal fusion. From 2009 to 2013, total cost sharing per inpatient hospitalization increased by 37%, from $738 in 2009 (95% CI, $736-$740) to $1013 in 2013 (95% CI, $1011-$1016), after adjusting for inflation and case-mix differences. This rise was driven primarily by increases in the amount applied to deductibles, which grew by 86% from $145 in 2009 (95% CI, $144-$146) to $270 in 2013 (95% CI, $269-$271), and by increases in coinsurance, which grew by 33% over the study period from $518 in 2009 (95% CI, $516-$520) to $688 in 2013 (95% CI, $686-$690). In 2013, total cost sharing was highest for enrollees in individual market plans ($1875 per hospitalization; 95% CI, $1867-$1883) and consumer-directed health plans ($1219; 95% CI, $1216-$1223). Cost sharing varied substantially across regions, diagnoses, and procedures. Mean out-of-pocket spending among commercially insured adults exceeded $1000 per inpatient hospitalization in 2013. Wide variability in out-of-pocket spending merits greater attention from policymakers.

Do “Consumer-Directed” health plans bend the cost curve over time?

“Consumer-Directed” Health Plans (CDHPs), those with high deductibles and personal medical accounts, are intended to reduce health care spending through greater patient cost exposure. Prior research agrees that in the first year, CDHPs reduce spending. There is little research and in it results are mixed regarding the impact of CDHPs over the longer term. We add to this literature with an intent-to-treat, difference-in-differences analysis of health care spending over up to three years post CDHP offer among 13 million person-years of data from 54 large US firms, half of which offered CDHPs. To strengthen the identification, we balance observables over time within firm, by developing weights through a machine learning algorithm, generalized boosted regression. We find that spending is reduced for those in firms offering CDHPs in all three years post offer relative to firms continuing to offer lower-deductible plans. The reductions are driven by spending decreases in outpatient care and pharmaceuticals, with no evidence of increases in emergency department or inpatient care over the three-year window.

CONSUMER‐DIRECTED HEALTH PLANS: A REVIEWOF THE EVIDENCE

AbstractThe number of people enrolled in consumer‐directed health plans (CDHPs) has increased dramatically over the last decade. We review the empirical literature on the effects of CDHPs, which is based on the experience of these plans in the employer‐sponsored market. Studies indicate that CDHPs reduce health care spending by approximately 5–15 percent relative to similar plans with lower deductibles and without spending accounts. Spending reductions are concentrated among healthier enrollees and are driven by reductions in the use of outpatient services and pharmaceuticals. There is little evidence on whether they reduce the use of low‐value services.

Evaluation of a Comprehensive Employee Wellness Program at an Organization With a Consumer-Directed Health Plan

Consumer-directed health plans (CDHPs) are popular among employers in the United States. This study examined an employee wellness program and its association with employee health in an organization that recently initiated a CDHP. This retrospective observational analysis compared the health risks, employer-paid health care costs, and short-term disability absences of employees of a large financial services corporation from 2009 to 2010. The two-time health risk appraisal participants had a significant improvement in the percentage of employees in the overall low-risk category. The average annual employer-paid medical and pharmacy costs did not significantly change. For employees who improved their health risk category, there was a commensurate change in costs and absences. In a difficult economic climate, this organization began a health promotion program for employees as well as a new CDHP benefit structure. No short-term reduction in health care usage or overall health status was observed.

Employer Health and Productivity Roadmap™ Strategy

The National Institute for Occupational Safety and Health Total Worker Health™ Program defines essential elements of an integrated health protection and health promotion model to improve the health, safety, and performance of employers and employees. The lack of a clear strategy to address the core drivers of poor health, excessive medical costs, and lost productivity has deterred a comprehensive, integrated, and proactive approach to meet these challenges. The Employer Health and Productivity Roadmap™, comprising six interrelated and integrated core elements, creates a framework of shared accountability for both employers and their health and productivity partners to implement and monitor actionable measures that improve health, maximize productivity, and reduce excessive costs. The strategy is most effective when linked to a financially incentivized health management program or consumer-directed health plan insurance benefit design.

Risk selection into consumer-directed health plans: an analysis of family choices within large employers.

To identify the degree of selection into consumer-directed health plans (CDHPs) versus traditional plans over time, and factors that influence choice and temper risk selection. Sixteen large employers offering both CDHP and traditional plans during the 2004–2007 period, more than 200,000 families. We model CDHP choice with logistic regression; predictors include risk scores, in addition to family, choice setting, and plan characteristics. Additional models stratify by account type or single enrollee versus family. Risk scores, family characteristics, and enrollment decisions are derived from medical claims and enrollment files. Interviews with human resources executives provide additional data. CDHP risk scores were 74 percent of traditional plan scores in the first year, and this difference declined over time. Employer contributions to accounts and employee premium savings fostered CDHP enrollment and reduced risk selection. Having to make an active choice of plan increased CDHP enrollment but also increased risk selection. Risk selection was greater for singles than families and did not differ between HRA and HSA-based CDHPs. Risk selection was not severe and it was well managed. Employers have effective methods to encourage CDHP enrollment and temper selection against traditional plans.

Consumer-Directed Health Plans Reduce The Long-Term Use Of Outpatient Physician Visits And Prescription Drugs

Consumer-directed health plans (CDHPs) are designed to make employees more cost- and health-conscious by exposing them more directly to the costs of their care, which should lower demand for care and, in turn, control premium growth. These features have made consumer-directed plans increasingly attractive to employers. We explored effects of consumer-directed health plans on health care and preventive care use, using data from two large employers-one that adopted a CDHP in 2007 and another with no CDHP. Our study had mixed results relative to expectations. After four years under the CDHP, there were 0.26 fewer physician office visits per enrollee per year and 0.85 fewer prescriptions filled, but there were 0.018 more emergency department visits. Also, the likelihood of receiving recommended cancer screenings was lower under the CDHP after one year and, even after recovering somewhat, still lower than baseline at the study's conclusion. If CDHPs succeed in getting people to make more cost-sensitive decisions, plan sponsors will have to design plans to incentivize primary care and prevention and educate members about what the plan covers.

Price-Shopping in Consumer-Directed Health Plans.

We use health insurance claims data from 63 large employers to estimate the extent of price shopping for nine common outpatient services in consumer-directed health plans (CDHPs) compared to traditional health plans. The main measures of price-shopping include: (1) the total price paid on the claim, (2) the share of claims from low and high cost providers and (3) the savings from price shopping relative to choosing prices randomly. All analyses control for individual and zip code level demographics and plan characteristics. We also estimate differences in price shopping within CDHPs depending on expected health care costs and whether the service was bought before or after reaching the deductible. For 8 out of 9 services analyzed, prices paid by CDHP and traditional plan enrollees did not differ significantly; CDHP enrollees paid 2.3% less for office visits. Similarly, office visits was the only service where CDHP enrollment resulted in a significantly larger share of claims from low cost providers and greater savings from price shopping relative to traditional plans. There was also no evidence that, within CDHP plans, consumers with lower expected medical expenses exhibited more price-shopping or that consumers exhibited more price-shopping before reaching the deductible.

Impact of Emerging Health Insurance Arrangements on Diabetes Outcomes and Disparities: Rationale and Study Design

Consumer-directed health plans combine lower premiums with high annual deductibles, Internet-based quality-of-care information, and health savings mechanisms. These plans may encourage members to seek better value for health expenditures but may also decrease essential care. The expansion of high-deductible health plans (HDHPs) represents a natural experiment of tremendous proportion. We designed a pre–post, longitudinal, quasi-experimental study to determine the effect of HDHPs on diabetes quality of care, outcomes, and disparities. We will use a 13-year rolling sample (2001–2013) of members of an HDHP and members of a control group. To reduce selection bias, we will limit participants to those whose employers mandate a single health insurance type. The study will measure rates of monthly hemoglobin A1c, lipid, and albuminuria testing; availability of blood glucose test strips; and rates of retinal examinations, high-severity emergency department visits, and preventable hospitalizations. Results could be used to design health plan features that promote high-quality care and better outcomes among people who have diabetes.

Price Shopping in Consumer-Directed Health Plans.

We use health insurance claims data from 63 large employers to estimate the extent of price shopping for nine common outpatient services in consumer-directed health plans (CDHPs) compared to traditional health plans. The main measures of price shopping include (1) the total price paid on the claim, (2) the share of claims from low- and high-cost providers, and (3) the savings from price shopping relative to choosing prices randomly. All analyses control for individual and zip code level demographics and plan characteristics. We also estimate differences in price shopping within CDHPs depending on expected health care costs and whether the service was bought before or after reaching the deductible. For eight out of nine services analyzed, prices paid by CDHP and traditional plan enrollees did not differ significantly; CDHP enrollees paid 2.3% less for office visits. Similarly, office visits was the only service where CDHP enrollment resulted in a significantly larger share of claims from low-cost providers and greater savings from price shopping relative to traditional plans. There was also no evidence that, within CDHP plans, consumers with lower expected medical expenses exhibited more price shopping or that consumers exhibited more price shopping before reaching the deductible.

In Consumer-Directed Health Plans, A Majority Of Patients Were Unaware Of Free Or Low-Cost Preventive Care

Consumer-directed health plans are plans with high deductibles that typically require patients to bear no out-of-pocket costs for preventive care, such as annual physicals or screening tests, in order to ease financial barriers and encourage patients to seek such care. We surveyed people in California who had a consumer-directed health plan and found that fewer than one in five understood that their plan exempted preventive office visits, medical tests, and screenings from their deductible, meaning that this care was free or had a modest copayment. Roughly one in five said that they had delayed or avoided a preventive office visit, test, or screening because of cost. Those who were confused about the exemption were significantly more likely to report avoiding preventive visits because of cost concerns. Special efforts to educate consumers about preventive care cost-sharing exemptions may be necessary as more health plans, including Medicare, adopt this model.