[*] Associate, Katz, Kutter, Haigler, Alderman, Marks, Bryant & Yon, P.A., Tallahassee, Florida. J.D. with High Honors, 1993, Florida State University; B.S., 1981, Emory University. Return to text.

[**] Associate, Katz, Kutter, Haigler, Alderman, Marks, Bryant & Yon, P.A., Tallahassee, Florida. J.D. with High Honors, 1995, Florida State University; B.J., 1990, University of Nebraska-Lincoln. Return to text.

[1] "Managed care" is a broad term used to describe a variety of health plans which integrate the financing and delivery of health care services. Health maintenance organizations and PPOs are common managed care organizations. "Managed care organizations will generally use a variety of techniques such as utilization review, quality assurance programs, and preadmission certification to better manage the care that is delivered, with the goal of controlling utilization and cost, while still delivering quality care." FLA. H.R. COMM. ON HEALTH CARE, HEALTH CARE HANDBOOK 30-31 (1995). Return to text.

[2] In a survey of more than 250 of Florida's largest public and private sector employers representing more than 900,000 employees, 48% of these employers reported employees choosing managed care rather than indemnity coverage in the past year. Survey participants reported that plan configurations reflected a continuing shift toward managed care. Use of HMO plans increased from 5% in 1993 to 45% in 1994. WILLIAM M. MERCER, INC., 1994 FLORIDA HEALTH CARE COSTS AND BENEFITS: SURVEY RESULTS 2, 4, 6 (Sixth Annual Issue 1994). Nationally, current enrollment in HMOs is nearly 50 million, up from 3.6 million in 1973. Jerry Geisel, HMOs Ready To Give Up an Old Crutch, BUS. INS., Dec. 20, 1994, at 6, 6. Return to text.

[3] For example, the results of the Mercer survey indicate that the switch to managed care has produced cost reductions. Of those organizations where employee enrollment in managed care is now greater than enrollment in an indemnity plan, 80% reported that switching to managed care has helped reduce increases in health care coverage costs. WILLIAM M. MERCER, INC., supra note 2, at 4-6; see generally Geisel, supra note 2 (reporting that the rise in health care costs continued to be low in 1995). Return to text.

[4] See infra notes 29-94 and accompanying text. Return to text.

[5] Craig S. Palosky, Doctors Want Surgery on HMOs, TAMPA TRIB., Mar. 27, 1995, Nation/World Section, at 1. Return to text.

[6] Id. Return to text.

[7] See Palosky, supra note 5, at 5; see also infra notes 29-94 and accompanying text. Return to text.

[8] See, e.g., infra notes 29-94 and accompanying text. Return to text.

[9] See George Anders & Laura Johannes, Doctors Are Losing a Lobbying Battle to HMOs, WALL ST. J., May 15, 1995, at B1, B2. Return to text.

[10] In a traditional fee-for-service health insurance setting the insured chooses the provider for his or her treatment, regardless of the appropriateness of the particular doctor's credentials or specialty (if any). There are few or no economic incentives for the provision of treatment in an efficient, cost-effective manner. See Alphabet Soup, TIMES UNION (JACKSONVILLE), Sept. 25, 1995, First Business, at 10. Generally, in a fee-for-service setting, providers are reimbursed based on the amount and type of care given. The more services utilized, the more the provider is reimbursed. Return to text.

[11] See infra notes 101-171 and accompanying text. Return to text.

[12] HEALTHY HOMES 1994, THE FLORIDA HEALTH SECURITY PLAN 9 (Dec. 1993). Return to text.

[13] Id. Return to text.

[14] See id. at 10. Return to text.

[15] Jerry Geisel, Health Market Changes Spur 1% Drop in Costs, BUS. INS., Feb. 13, 1995, at 1, 10. Return to text.

[16] HEALTHY HOMES 1994, supra note 12, at 7-8. Return to text.

[17] See ANNE R. MARKUS ET AL., SPECIAL REPORT: SMALL GROUP MARKET REFORMS: A SNAPSHOT OF STATES' EXPERIENCE 1 (Feb. 1995). Return to text.

[18] 1992, Fla. Laws ch. 92-233, 117, at 328 (codified at FLA. STAT. 627.6699 (1995)). Return to text.

[19] Id. 5-7, at 244 (codified at FLA. STAT. 408.004-.006 (1995)). Return to text.

[20] Id. 1, at 241 (codified at FLA. STAT. 20.42 (1995)). Return to text.

[21] 1993, Fla. Laws ch. 93-129; see also Bruce D. Platt, A Summary of the Health Care and Insurance Reform Act of 1993: Florida Blazes the Trail, 21 FLA. ST. U. L. REV. 483, 483 (1993). Return to text.

[22] Fla. H.R. Comm. on Health Care, CS for SB 1914, SB 2006, SB 1784, SB 406 (1993) Staff Analysis 1 (final May 11, 1993) (on file with comm.). Return to text.

[23] See HEALTH LAW SERIES, HEALTH LAW HANDBOOK 51 (Alice G. Gosfield ed., 1994). Return to text.

[24] Id. at 52. Return to text.

[25] Id.; see also 1993, Fla. Laws ch. 93-128 (codified at FLA. STAT. 627.6699 (1995)); see also Platt, supra note 21, at 495. Return to text.

[26] Fla. HB 1459 (1995); Fla. HB 2823 (1994). Return to text.

[27] Id. Return to text.

[28] FLA. LEGIS., FINAL LEGISLATIVE BILL INFORMATION, 1995 REGULAR SESSION, HISTORY OF HOUSE BILLS at 302, HB 1459; FLA. LEGIS., FINAL LEGISLATIVE BILL INFORMATION, 1994 REGULAR SESSION, HISTORY OF HOUSE BILLS at 392, HB 2823; see Diane Hirth, Health Reform Looks 'Deader Than Dead,' ORLANDO SENT., May 5, 1995, at B5. Return to text.

[29] Fla. HB 841 (1995). Return to text.

[30] Fla. HB 541 (1995). Return to text.

[31] Fla. HB 723 (1995). Return to text.

[32] FLA. LEGIS., FINAL LEGISLATIVE BILL INFORMATION, 1995 REGULAR SESSION, HISTORY OF HOUSE BILLS at 267, HB 841; id. at 244, HB 541; id. at 257, HB 723. Return to text.

[33] See Anders & Johannes, supra note 9, at B1. Return to text.

[34] Id. Return to text.

[35] Id. Return to text.

[36] See Fla. HB 841 (1995); see also Fla. SB 1986 (1995). Return to text.

[37] Id. Return to text.

[38] Fla. HB 841, 100 (1995). The Act would have required HMOs and other managed care plans to inform prospective enrollees of a plan's coverage provisions and exclusions, treatment policies and any restrictions or limitations on services, prior authorization or review requirements, any financial arrangements or contracts a plan has with hospitals, physicians or other providers that would limit services, referral or treatment, including any financial incentives not to provide services, an explanation of how plan limits would impact enrollees, loss ratios, and enrollee satisfaction with a plan, including statistics on re-enrollment and enrollees' reasons for leaving a plan. Id. Return to text.

[39] See, e.g., Letter from William E. Coletti, Exec. Dir., Pinellas County Medical Soc'y, Inc., to the Editor, ST. PETE. TIMES, June 17, 1994, at A17. Return to text.

[40] A plan's member handbook is the document distributed to the enrollee explaining what services are available and how to access those services. All such handbooks are reviewed by the Florida Department of Insurance to ensure that HMOs make the required information available. See FLA STAT. 641.21(1)(f) (1995). Return to text.

[41] Interview with Ralph F. Scott, Ass't Gen. Counsel, State Affairs, Health Ins. Ass'n of Am., in Tallahassee, Fla. (Sept. 20, 1995). Return to text.

[42] See Fla. HB 841, 100(5)(b)1 (1995). Return to text.

[43] The authors understand that HMOs contract with many physicians to form the HMO's network. To list each service each physician could perform and each service each physician could not perform, would necessarily lead to hundreds of pages. Return to text.

[44] At a minimum these expenses would have included the cost of preparing the reports, the material needed for the reports, and the cost of storage. Return to text.

[45] See Fla. HB 841, 100(5)(b)4 (1995); see also Interview with Ralph F. Scott, supra note 41. Return to text.

[46] For example, the Act would have required the HMO to disclose every specific medical exclusion, including the names of every drug not included in the HMO's formularies. See Fla. HB 841, 100(5)(b)2 (1995). Such a list could consume many volumes and would be cumbersome and costly to publish. Moreover, pharmacies and drug manufacturers would find this information extremely valuable in their negotiations with HMOs. A patient or potential subscriber who needs this information can obtain it by calling the HMO. Interview with Ralph F. Scott, supra note 41. Return to text.

[47] Interview with Ralph F. Scott, supra note 41. Return to text.

[48] Fla. HB 841, 100(5)(d)9 (1995). Return to text.

[49] Id. at 100(5)(d). Return to text.

[50] Id. The Act would have further provided that if economic considerations were a factor in the decision to grant or deny credentials, any economic profiling of a physician would have to take into account features of the physician's practice which could account for costs which are higher or lower than expected, such as case mix and age of patients. Id. Decisions regarding granting or denying an application would have been required to be on the record. Id. Return to text.

[51] The effect of this legislation would be virtually the same as that of the proposed "Any Willing Provider" legislation. See discussion infra notes 81-87 and accompanying text. Return to text.

[52] See id. A plan could not have denied, reduced, or withdrawn credentials without providing the physician notice, an opportunity for a hearing before an arbitrator or hearing officer, and an opportunity to complete a "corrective action plan." Id. These due process requirements could only have been denied in cases where "imminent harm to patient health" existed, or where the physician was unable to practice medicine due to action by the Board of Medicine or another government agency. Id. A physician would have had the right to appeal the decision of the arbitrator or hearing officer. Id. Return to text.

[53] Your Right To Select Your Doctor and Hospital-Patient Freedom of Choice, MED. HEALTH CARE ALLIANCE (on file with authors); see generally Legislature: Protect Patients, Act To Curb Growing HMO Power, TALL. DEM., Feb. 15, 1995, at A8. Return to text.

[54] See DeMarco v. Publix Super Markets, 384 So. 2d 1253, 1254 (Fla. 1980). As an "at-will" employment state, Florida employers are not generally required to furnish specific reasons for firing employees. Return to text.

[55] See generally Martin Dyckman, Self-Serving Doctors, ST. PETE. TIMES, Mar. 16, 1995, at A19. Return to text.

[56] Id. Return to text.

[57] Fla. HB 841, 100 (1995); see also infra notes 81-87 and accompanying text. Return to text.

[58] See generally Dyckman, supra note 55, at A19; see also BLUE CROSS BLUE SHIELD OF FLORIDA, PATIENT PROTECTION ACT POLICY STATEMENT (1995) (on file with authors). Return to text.

[59] See Telephone Interview with Richard F. Dorf, Exec. Dir. of Fla. Ass'n of HMOs (Sept. 20, 1995); Interview with Ralph F. Scott, supra note 41. Return to text.

[60] See e.g. John Dunbar, HMOs Fight Patient Choice, TIMES UNION (JACKSONVILLE), Apr. 25, 1995, at A1, A4. Return to text.

[61] Id. Return to text.

[62] The American Medical Association has emphasized this concern in its advertising campaign promoting its anti-managed care proposals. One such ad warned, "Would you rather trust your life to an MD or an MBA?" See John Fairhall, Clash of the Titans: Doctors, HMOs, Insurers on Health Care, BALTIMORE SUN, July 3, 1994, at E1. Much of the rhetoric surrounding the AMA's model of this provision depicts managed care plans as placing medical decision making "in the hand of corporate clerks and government bureaucrats." Steven Brostoff, AMA Backing "Anti-HMO" Legislation, NAT'L UNDERWRITER, LIFE & HEALTH INS., May 30, 1994, at 1. "If we don't keep the health plans honest," the AMA warns, "some anonymous clerk sitting at the end of a 1-800 number is going to take over for your doctor." Adrianne Appel, AMA Tries Pressure on HMOs: Ad Campaign Seeks Support for Legislation That Would Require More Health-Plan Information, PEORIA J. STAR, May 29, 1994, at C15 (quoting Dr. Lonnie Bristow, Chairperson of the AMA Board). Return to text.

[63] Fla. H.B. 841, 100 (1995). Return to text.

[64] Id. Return to text.

[65] Interview with Ralph F. Scott, supra note 41; Telephone Interview with Richard F. Dorf, supra note 59. Return to text.

[66] HMO accreditation agencies require that these review decisions be made by a physician. Standards for the Accreditation of Managed Care Associations, in NCQA MANUAL 1995 EDITION, 25, 25 (1995) (on file with authors). Currently, Florida law requires all HMOs to be accredited within one year of obtaining their certificate of authority to operate. FLA. STAT. 641.512 (1995). Return to text.

[67] Interview with Ralph F. Scott, supra note 41; Telephone Interview with Richard F. Dorf, supra note 59. Return to text.

[68] See Telephone Interview with Richard F. Dorf, supra note 59. Return to text.

[69] See FLA. STAT. 641.511 (1995); see also NCQA MANUAL, supra note 66, at 33-34; Phil Galewitz, As HMOs Proliferate, So Do Complaints About Them, PALM BCH. POST, Oct. 15, 1995, at E4 (interview with Linda Enfinger of AHCA explaining the grievance process). Return to text.

[70] See FLA. STAT. 641.495(8), 641.21(1)(e) (1995). The grievance procedure must be contained in the HMO's contract offered for its subscribers. See id. 641.495(8). The master contract must be approved by the Department of Insurance. See id. 641.21(1)(f), 641.31(3). Return to text.

[71] See id. 641.512. Return to text.

[72] See id. 641.511. Return to text.

[73] Interview with Ralph F. Scott, supra note 41; Telephone Interview with Richard F. Dorf, supra note 59. Return to text.

[74] Fla. HB 841, 17 (1995) (codified at Fla. Stat. 408.7054 (1995)). The Act stated that creation of "health care provider networks" would "enhance competition" by allowing independent health care providers and small group practices to participate in the market alongside the large corporate networks. Id. The Act intended to exempt these networks of independent physicians from state antitrust laws and to provide immunity from federal antitrust laws so that they could engage in collective activity with respect to disseminating information on cost and pricing data, payment procedures, patient referral protocols, administrative matters, and dispute resolution mechanisms. Id. Return to text.

[75] See, e.g., Fairhall, supra note 62, at E1. Return to text.

[76] Id. Return to text.

[77] See generally FLORIDA ASSOCIATION OF HEALTH MAINTENANCE ORGANIZATIONS ANTITRUST POLICY STATEMENT (1995) (on file with authors). Return to text.

[78] Telephone Interview with Richard F. Dorf, supra note 59; see also Palosky, supra note 5, at 5 (quoting Carl Homer speaking generally about the Patient Protection Act). Return to text.

[79] In 1993 the Department of Justice and the Federal Trade Commission (together, the "Agencies") set forth six policy statements regarding the enforcement of antitrust policies relating to the health care industries. In 1994, these were revised and new policy statements were added. The statements describe certain health care antitrust "safety zones," which are circumstances under which the Agencies will not challenge conduct under the antitrust laws. These "safety zones" are: I) "Mergers Among Hospitals," II) "Hospital Joint Ventures Involving High Technology or Other Expensive Health Care Equipment," III) "Hospital Joint Ventures Involving Specialized Clinical or Other Expensive Health Care Services," IV) "Providers' Collective Provision of Non-Fee-Related Information to Purchasers of Health Care Services," V) "Providers' Collective Provision of Fee-Related Information to Purchasers of Health Care Services," VI) "Provider Participation in Exchanges of Price and Cost Information," VII) "Joint Purchasing Arrangements Among Health Care Providers," VIII) "Physician Network Joint Ventures," and IX) "Analytical Principles Relating to Multiprovider Networks." See generally U.S. DEP'T OF JUSTICE AND THE FTC, STATEMENTS OF ENFORCEMENT POLICY AND ANALYTICAL PRINCIPLES RELATING TO HEALTH CARE AND ANTITRUST (Sept. 27, 1994). Return to text.

[80] See generally GROUP HEALTH POLICY, PRUDENTIAL ANTITRUST POLICY STATEMENT & PRUDENTIAL ANTI- MANAGED CARE LAWS POLICY STATEMENT (Mar. 1995). Return to text.

[81] Fla. HB 541, 1 (1995). Return to text.

[82] Id. Return to text.

[83] Id. Return to text.

[84] See supra notes 59-60 and accompanying text. Return to text.

[85] Blue Cross and Blue Shield estimated that premiums would increase by as much as 14% if "Any Willing Provider" legislation passed. Dunbar, supra note 60, at A1. In its fiscal evaluation of Florida's proposed "Any Willing Provider" legislation, Arthur Anderson and Associates concluded that the economic impact of this provision would be significant. See Fla. H.R. Comm. on Health Care, HB 541 (1995) Staff Analysis 5 (Feb. 27, 1995) (on file with comm.). The fiscal evaluation also predicted that administrative expenses would increase due to greater network size. Id. Return to text.

[86] See FLA. STAT. 641.512(4) (1995); see also NCQA MANUAL, supra note 66, at 27-31. Return to text.

[87] See FLORIDA ASSOCIATION OF HEALTH MAINTENANCE ORGANIZATIONS, ANY WILLING PROVIDER POLICY STATEMENT 2 (1995) (on file with authors); see also BLUE CROSS BLUE SHIELD OF FLORIDA, supra note 58. Return to text.

[88] See Dunbar, supra note 60, at A4. Return to text.

[89] See, e.g., CAPITAL HEALTH PLAN MEMBER HANDBOOK 4 (Mar. 1992) (on file with authors); see also Susan J. Stayn, Securing Access to HMOs, 94 COLUM. L. REV. 1674, 1679-80 (1994); see also FLA STAT. 641.21(1)(f) (1995). Return to text.

[90] See Stayn, supra note 89, at 1679-82; see also FLORIDA DEPT. OF INS., 1994, 1995 HEALTH MAINTENANCE ORGANIZATION CONSUMERS' GUIDE 1-2 (1994). Return to text.

[91] See generally FLORIDA ASSOCIATION OF HEALTH MAINTENANCE ORGANIZATIONS, DIRECT ACCESS POLICY STATEMENT (1995) (on file with authors). Return to text.

[92] Fla. HB 723 (1995). Return to text.

[93] Id. Return to text.

[94] Id. Return to text.

[95] Palosky, supra note 5, at 5 (quoting Rep. Everett Kelly, D-Tavares); see also Dan Morgan, HMO Trend Squeezes Big-Fee Medical Specialists, WASH. POST, July 17, 1994, at A1. Return to text.

[96] Palosky, supra note 5, at 5 (providing an example of these attempts). Return to text.

[97] Id. (quoting Rep. Everett Kelly, D-Tavares). Return to text.

[98] Fla. HB 841, 100 (1995). Return to text.

[99] This analysis examines several recent studies published in medical journals such as the Journal of the American Medical Association, the New England Journal of Medicine, and the Annals of Internal Medicine. In an attempt to limit subjective biases, the publications listed in this analysis primarily concentrated on the difference in reported outcomes between HMOs and fee-for-service providers, as well as comparisons of the likelihood of receiving specific services and diagnostic tests that are demonstrated to be indicators of quality health care. These studies conclude that, in an examination of specific health outcomes measured, the quality of care provided to patients enrolled in HMOs is gener ally as good as, perhaps better than, the quality of care received by patients enrolled in traditional fee-for-service insurance plans. This observation is not new. A 1980 article reviewing 1958-1979 literature on the quality of health care in HMOs concluded that the quality of care delivered by HMOs was generally better than, or comparable to, fee-for-service care. See generally Frances C. Cunningham & John W. Williamson, How Does the Quality of Health Care in HMOs Compare to that in Other Settings? An Analytic Literature Review: 1958 to 1979, 1 GROUP HEALTH J. 4 (1980). Return to text.

[100] See infra notes 101- 71 and accompanying text. Return to text.

[101] Robert H. Miller & Harold S. Luft, Managed Care Plan Performance Since 1980, 271 JAMA 1512, 1516 (1994). Return to text.

[102] I. Steven Udvarhelyi et al., Comparison of the Quality of Ambulatory Care for Fee-for-Service and Prepaid Patients, 115 ANNALS INTERNAL MED. 394, 394 (1991). Return to text.

[103] Id. at 397-98. Return to text.

[104] Id. Return to text.

[105] Id. at 398. Return to text.

[106] Id. Return to text.

[107] Id. at 399. Return to text.

[108] Diane M. Makuc et al., Health Insurance and Cancer Screening Among Women, in ADVANCE DATA FROM VITAL AND HEALTH STATISTICS OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION, NATIONAL CENTER FOR HEALTH STATISTICS, No. 254 (Aug. 1994). Return to text.

[109] Id. at 5. Return to text.

[110] Id. at 4. Return to text.

[111] Id. Return to text.

[112] Id. Return to text.

[113] Id. at 5. Return to text.

[114] Gerald F. Riley et al., Stage of Cancer at Diagnosis for Medicare HMO and Fee-for-Service Enrollees, 84 AM. J. PUB. HEALTH 1598, 1600 (1994). Return to text.

[115] Id. Return to text.

[116] Id. Return to text.

[117] Id. at 1600-01. Return to text.

[118] Id. Return to text.

[119] Id. at 1601. Return to text.

[120] Id. at 1602. Return to text.

[121] Id. Return to text.

[122] Id. at 1601. An exception was found in patients with stomach cancer, where HMO enrollment was associated with distant stage disease. Id.; see also Howard P. Greenwald & Curtis J. Henke, HMO Membership, Treatment, and Mortality Risk Among Prostatic Cancer Patients, 82 AM. J. PUB. HEALTH 1099, 1100 (1992) (finding that the stage at diagnosis of prostate cancer did not systematically vary among HMO and fee-for-service patients). Return to text.

[123] Nicole Lurie et al., The Effects of Capitation on Health and Functional Status of the Medicaid Elderly, 120 ANNALS INTERNAL MED. 506, 506 (1994). Return to text.

[124] Id. Return to text.

[125] Id. Return to text.

[126] Id. at 508. Return to text.

[127] Id. at 506. Return to text.

[128] Id. Return to text.

[129] Jeanette A. Preston & Sheldon M. Retchin, The Management of Geriatric Hypertension in Health Maintenance Organizations, 39 J. AM. GERIATRICS SOC'Y 683, 683 (1991). Return to text.

[130] Id. at 686. Return to text.

[131] Id. Return to text.

[132] Id. Return to text.

[133] Id. Return to text.

[134] Id. Return to text.

[135] Id. Return to text.

[136] Id. at 689. Return to text.

[137] Id. at 683; see also Ron Winslow, Elderly Get Similar Quality At HMOs As At Traditional Settings, Study Says, WALL ST. J., May 18, 1994, at B4. Return to text.

[138] See R. Burciaga Valdez et al., Prepaid Group Practice Effects on the Utilization of Medical Services and Health Outcomes for Children: Results From a Controlled Trial, 83 PEDIATRICS 168, 168 (1989). Return to text.

[139] Id. at 179. Return to text.

[140] Id. at 168. The cost sharing in the fee-for-service plans varied from 0% to 95%. Id. Return to text.

[141] Id. Return to text.

[142] Id. at 175 (comparing children assigned to an HMO with children assigned to a co-pay fee-for-service plan). Return to text.

[143] Id. at 179. Return to text.

[144] Paula Braveman et al., Insurance-Related Differences in the Risk of Ruptured Appendix, 331 NEW ENG. J. MED. 444, 446 (1994). Return to text.

[145] Id. at 447. Return to text.

[146] Id. at 448. Return to text.

[147] Id. Return to text.

[148] Steven D. Pearson et al., The Impact of Membership in a Health Maintenance Organization on Hospital Admission Rates for Acute Chest Pain, 29 HEALTH SERVS. RES. 59, 59 (1994). Return to text.

[149] Id. at 64-66. Return to text.

[150] Id. Return to text.

[151] Id. at 64-65. Return to text.

[152] Id. at 70. Return to text.

[153] Id. at 71. Return to text.

[154] Id. at 72. Return to text.

[155] Id. Return to text.

[156] Id. at 71. Return to text.

[157] Miller & Luft, supra note 101, at 1515. Return to text.

[158] Id. at 1516. Return to text.

[159] KENNETH M. LANGA & ELLIOT J. SUSSMAN, The Effect of Cost-Containment Policies on Rates of Coronary Revascularization in California, 329 NEW ENG. J. MED. 1784, 1787 (1993). Return to text.

[160] Id. at 1788. Return to text.

[161] Id. at 1789. Return to text.

[162] Greenwald & Henke, supra note 122, at 1100. Return to text.

[163] Id. at 1102. Return to text.

[164] Id. at 1103. Return to text.

[165] Id. Return to text.

[166] Riley et al., supra note 114, at 1602-03. Return to text.

[167] Greenwald & Henke, supra note 122, at 1102. Return to text.

[168] Id. at 1103-04. Return to text.

[169] Id. at 1104. Return to text.

[170] Lurie et al., supra note 123, at 506. Return to text.

[171] Id. Return to text.


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