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The Metamorphosis of Managed Care: Implications for Health Reform Internationally

Published online by Cambridge University Press:  01 January 2021

Extract

Many writers suggest that managed care had a brief life and that we are now in a post-managed care era. Yet managed care has had a long history and continues to thrive. Writers also often assume that managed care is a fixed entity, or focus on its tools, rather than the context in which it operates and the functions it performs. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system.

This article argues that private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures; and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care internationally.

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Independent
Copyright
Copyright © American Society of Law, Medicine and Ethics 2010

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References

This article develops the themes that I presented in a talk at the 1st International Conference on Health Care Reform, University of Mexico, Mexico City, April 24, 2009. Rodwin, M. A., “The Metamorphosis of Managed Care,” in Rivero Serrano, O., ed., 1er Congreso Internacional de Medicina y Salud (México, D.F.: Universidad Nacional Autonoma de México, 2010). For the standard text book on managed care, see Kongstvedt, P., Essentials of Managed Health Care, 5th ed. (Boston: Jones and Bartlett, 2007).Google Scholar
Hirschman, A. O., Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States (Cambridge: Harvard University Press, 1970); Hirschman, A. O., “Exit and Voice: An Expanding Sphere of Influence,” in Rival Views of Market Society and Other Recent Essays (New York: Viking Press, 1970).Google Scholar
Weller, C. D., “Free Choice as a Restraint of Trade, and the Counterintuitive Contours of Competition,” Health Matrix 33, no. 2 (1985): 323; Rodwin, M. A., “Exit and Voice in American Health Care,” Michigan Journal of Law Reform 32, no. 4 (1999): 10411067; Rodwin, M. A., “Consumer Voice and Representation in Managed Health Care,” Journal of Health Law 34, no. 2 (2001): 223272.Google Scholar
For a history and analysis and history of commercialism and conflicts of interest in American medicine from the colonial period until the present, see, Rodwin, M. A., “Medical Commerce, Physician Entrepreneurialism, and Conflicts of Interest,” Cambridge Quarterly of Healthcare Ethics 16, no. 4 (2007): 387397.CrossRefGoogle Scholar
Rodwin, M. A., Medicine, Money and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993).Google Scholar
Hibbard, J. H. and Weeks, E. C., “Consumerism in Health Care: Prevalence and Predictors,” Medical Care 25, no. 11 (1987): 10191032.CrossRefGoogle Scholar
Katz, J., The Silent World of Doctor and Patient (New York: The Free Press, 1984).Google Scholar
Parsons, T., “The Sick Role and the Role of the Physician Reconsidered,” Milbank Quarterly 53, no. 257 (1975): 266271.Google Scholar
Rodwin, M. A., “Patient Accountability and Quality of Care: Lessons from Medical Consumerism and the Patients' Rights, Women's Health and Disability Rights Movements,” American Journal of Law and Medicine 20, nos. 1 & 2 (1994): 147167.CrossRefGoogle Scholar
Derbyshire, R. C., Medical licensure and discipline in the United States (Baltimore: Johns Hopkins Press, 1969): at 77–85; Ameringer, C. F., State Medical Boards and the Politics of Public Protection (Baltimore: Johns Hopkins University Press, 1999).Google Scholar
Weiler, P. C., Newhouse, J. P., Johnson, W. G., Brennan, T., and Hiatt, H., A Measure of Malpractice: Medical Injury, Malpractice Litigation, and Patient Compensation (Cambridge: Harvard University Press, 1993).Google Scholar
For some of the leading histories of American medicine and health policy, see Starr, P., The Social Transformation of American Medicine (New York: Basic Books, 1982); Stevens, R., In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989).Google Scholar
Adverse selection is not limited to patients or purchasers. Insurers can also engage in adverse selection by marketing insurance to individuals less likely to need medical services than average or by excluding high risk individuals and groups.Google Scholar
Burrows, J. G., Organized Medicine in the Progressive Era: The Move toward Monopoly (Baltimore: Johns Hopkins University Press, 1977): at Chap. 8, “Contract Practice,” 119132. Chase-Lubitz, J. F., “The Corporate Practice of Medicine Doctrine: An Anachronism in the Modern Health Care Industry,” Vanderbilt Law Review 40, no. 2 (1987): 445488.Google Scholar
Cunningham, R. III and Cunningham, R. M. Jr., The Blues: A History of the Blue Cross and Blue Shield System (Dekalb: Northern Illinois University Press, 1997).Google Scholar
See Starr, , supra note 12.Google Scholar
Schwartz, J. L., “Early History of Prepaid Medical Care Plans,” Bulletin of the History of Medicine 39, no. 5 (1965): 450475; Hansen, H. R., “Laws Affecting Group Health Plans,” Iowa Law Review 35, no. 2 (1950): 209236.Google Scholar
They succeeded, despite the federal government successfully prosecuting the AMA in 1942 for violation of antitrust laws by excluding physicians in Group Health Association, Washington, D.C.Google Scholar
Laufer, J., “Ethical and Legal Restrictions on Contract and Corporate Practice of Medicine,” Law and Contemporary Problems 6, no. 4 (1939): 516–27. See Chase-Lubitz, , supra note 14.CrossRefGoogle Scholar
Statistics on U.S. population from Statistical Abstracts of the U.S. Statistics on enrollment in insurance plans from Statistical Abstracts of the U.S. Statistics on enrollment in insurance plans from: Fein, R., Medical Care, Medical Cost: The Search for a National Health Insurance Policy (Cambridge: Harvard University Press, 1986): at Chapter 1, “In Sickness and in Health.”Google Scholar
States could cover additional low-income groups and choose the income eligibility level for their qualifying. Today, Medicaid covers less than half of all individuals, and only one-third of childless adults, falling below the federal poverty level. Rosenbaum, S., “Medicaid and National Health Care Reform,” New England Journal of Medicine 36, no. 21 (2009): 20092012.CrossRefGoogle Scholar
Marmor, T., The Politics of Medicare, 2nd ed. (Hawthorn NY: Aldine Transaction, 1994); Oberlander, J., The Political Life of Medicare (Chicago: University of Chicago Press, 2003).Google Scholar
Organization for Economic Co-operation and Development Health Data 2002.Google Scholar
P.L. 92–603 (1972); McDonough, J., “Tracking the Demise of State Hospital Rate-Setting,” Health Affairs 16, no. 1 (1997): 142149.CrossRefGoogle Scholar
However, planning agencies did not directly control funds for construction or reimbursement, which undercut their effectiveness. See Rodwin, V. G., The Health Planning Predicament: France, Québec, England, and the United States (Berkeley: University of California Press, 1984).CrossRefGoogle Scholar
States were required to create state health planning agencies and implement a system to issue certificates of need which would be necessary for new hospital construction or expansion. Health System Agencies regulated providers, but the majority of members represented consumers. The boards would make recommendations to state agencies on issuing certificates of need, and to the federal government on use of federal funds. Planning agencies and PSROs were supposed to develop explicit standards for determining need. Employers and consumer groups participated in decisions about allocation of resources which had previously been left to physicians and hospitals.Google Scholar
At the time, many leaders believed Congress would soon pass NHI. Because of this, Nixon later introduced his own proposal for NHI, which might have become law had not the Watergate scandal forced his resignation.Google Scholar
Altman, S. and Eichenholtz, J., “Inflation in the Health Industry: Causes and Cures,” in Altman, S. and Eichenholtz, J., eds., Economics and Health (Cambridge: MIT Press, 1981).Google Scholar
Brown, L. D., Politics and Health Care Organization: HMO's as Federal Policy (Washington, D.C.: The Brookings Institution, 1983).Google Scholar
See Rodwin, (2001) supra note 3; Rodwin, (1999), supra note 3; Rodwin, M. A., “Conflicts in Managed Care,” New England Journal of Medicine 332, no. 9 (1995): 604607.CrossRefGoogle Scholar
Hurley, R., Freund, D., and Paul, J., Managed Care in Medicaid: Lessons for Policy and Program Development (Ann Arbor: Health Administration Press, 1993).Google Scholar
Hellinger, F. J., “The Impact of Financial Incentives on Physician Behavior in Managed Care Plans: A Review of the Evidence,” Medical Care Research Review 153, no. 3 (1996): 294314.CrossRefGoogle Scholar
1976 Amendments to the HMO Act.Google Scholar
Data from Inter-study, summarized in Gray, B., “The Rise and Decline of the HMO,” in Stevens, R., Rosenberg, C. E., and Burns, L. R., History and Health Policy in the United States: Putting the Past Back In (New Brunswick: Rutgers University Press, 2006): 309339, at 312. By 2001, HMO enrollment declined to 71.8 million. The Inter-study Competitive Edge 3.2., Excelsior, MN, Decision Resources, Inc.Google Scholar
Goldfarb v. Virginia State Bar, 421 U.S. 773 (1975); Ameringer, C. F., The Health Care Revolution: From Medical Monopoly to Market Competition (Berkeley: University of California Press, 2008).Google Scholar
In re American Medical Ass'n, 94 F.T.C. 701, 801 (1979); [1979–1983 Transfer Binder] Trade Reg. Rep. (CCH) p 21,955 at 22,418–19.Google Scholar
See McDonough, , supra note 24.Google Scholar
Goldsmith, J., Can Hospitals Survive? The New Competitive Health Care Market Homewood: Dow Jones-Irwin, 1981).Google Scholar
Touche, R. and Touche, C., Investors' Guide to Health Maintenance Organizations (Washington, D.C.: U.S. Government Printing Office, 1982). See Gray, , supra note 34.Google Scholar
Sound Health Ass'n v. Comm'r, 71 T.C. 158 (1978).Google Scholar
See Inter-study, The Inter-study 7 HMO summary, Excelsior, MN, Decision Resources, Inc., 1985; Inter-study, National HMO firms 1986: A Report on Companies That Own or Operate HMOs in Two or More States, Excelsior, MN, Decision Resources, Inc., 1987.Google Scholar
Williams, C., Treloar, J., Lundy, J., Wang, J., and Levitt, L., Trends & Indicators in the Changing Health Care Marketplace, 2002 Chart Book, The Henry J. Kaiser Family Foundation Center for Medicare & Medicaid Services, Menlo Park, 2002.Google Scholar
See the Health Affairs theme issue on conversion, “Hospital & Health Plan Conversion,” in Health Affairs 16, no. 2 (1997). See especially, Gray, B., supra note 34. “Conversion of HMOs and Hospitals: What's at Stake?” Health Affairs 16, no. 2 (1999): 2947; Claxton, G., Feder, J., Shactman, D., and Altman, S., “Public Policy Issues in Nonprofit Conversions: An Overview,” Health Affairs 16, no. 2 (1997): 928; Kuttner, R., “Must Good HMOs Go Bad? The Commercialization of Prepaid Group Health Care,” New England Journal of Medicine 338, no. 21 (1998): 15581563CrossRefGoogle Scholar
Luft, H. S., Health Maintenance Organizations: Dimensions of Performance (New Brunswick: Transaction Books, 1987).Google Scholar
Luft's comment was made in public presentation at Heller School, Brandeis University in the fall of 1986. However, Luft and others did evaluate managed care performance. See, e.g., Miller, R. H. and Luft, H. S., “Managed Care Plan Performance Since 1980: A Literature Analysis,” Journal of the American Medical Association 271, no. 19 (1994): 15121519; Miller, R. H. and Luft, H. S., “Does Managed Care Lead to Better or Worse Quality of Care?” Health Affairs 16, no. 5 (1997): 725; Miller, R. H. and Luft, H. S., “HMO Plan Performance Update: An Analysis of the Literature, 1997–2001,” Health Affairs 21, no. 4 (July/August 2002): 6386.CrossRefGoogle Scholar
Gabel, J., “Ten Ways HMOs Have Changed During the 1990s,” Health Affairs 16, no. 3 (1997): 134145; Draper, D. A., Hurley, R. E., Lesser, C. S., and Strunk, B. C., “The Changing Face of Managed Care,” Health Affairs 21, no. 1 (2002): 1123.CrossRefGoogle Scholar
Weiner, J. and de Lissovoy, G., “Raising a Tower of Babel: A Taxonomy for Managed Care and Health Insurance Plans,” Journal of Health Politics Policy and Law 18, no. 1 (1993): 75103; Welch, W. P., Hillman, A., and Pauly, M. V., “Toward New Typologies for HMOs,” The Milbank Quarterly 68, no. 2 (1990): 221243.CrossRefGoogle Scholar
For a history of utilization review programs see, Gray, B. H. and Fields, M. J., eds., Controlling Costs and Changing Patient Care: The Role of Utilization Management (Washington, D.C.: National Academy Press, 1989).Google Scholar
See Gabel, , supra note 46.Google Scholar
Firshein, J., “Measuring Progress towards Practice Guidelines, Clinical Guidelines, and Doctors,” Business and Health 38 (1995).Google Scholar
Shapiro, M. F. and Wenger, N. S., “Rethinking Utilization Review,” New England Journal of Medicine 333, no. 20 (1995): 13531354; Kassirer, J. P., “The Use and Abuse of Practice Profiles,” New England Journal of Medicine 330, no. 9 (1994): 634636.CrossRefGoogle Scholar
Robinson, J. C., “The Future of Managed Care Organizations,” Health Affairs 18, no. 2 (1999): 724.CrossRefGoogle Scholar
National Industry Council for HMO Development, The Health Maintenance Organization Industry: Ten Year Report 1973–1983, Council for HMO Development, Washington, D.C., 1983; see Inter-study (1987), supra note 41.Google Scholar
Robinson, J. C., “Consolidation and the Transformation of Competition in Health Insurance,” Health Affairs 23, no. 6 (2004): 1123.CrossRefGoogle Scholar
See Starr, , supra note 12, at 429, 442; Kronick, R., Goodman, D. C., and Wennberg, J. et al., “The Marketplace in Health Care Reform: The Demographic Limitations of Managed Competition,” New England Journal of Medicine 328, no. 2 (1993): 148152; Hirschman, A. O., Exit, Voice, and Loyalty: Responses to Decline in Markets, Organizations, and States (Cambridge: Harvard University Press, 1970): at 5760.Google Scholar
Robinson, J. C., “The Future of Managed Care Organizations,” Health Affairs 18, no. 2 (1999): 724.CrossRefGoogle Scholar
See Weiner, and de Lissovoy, , supra note 47.Google Scholar
Hacker, J. S. and Marmor, T. R., “How Not to Think about Managed Care,” Michigan Journal of Law Reform 32 (1999): 661684.Google Scholar
Enthoven, A. C., “Consumer Choice Health Plan: A National Health Insurance Proposal Based on Regulated Competition in the Private Sector,” New England Journal of Medicine 298, no. 12 (1978): 650658 (Part 1) and 298, no. 13 (1978): 709720 (Part 2); Enthoven, A. C., Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care (Reading: Addison Wesley, 1980); Enthoven, A. C., “The History and Principles of Managed Competition,” Health Affairs 12, Supp. 1 (1993): 2448.Google Scholar
White House Domestic Council, The President's Health Security Plan: The Complete Draft and Final Reports of the White House Domestic Council, 1993.Google Scholar
Skocpol, T., Boomerang: Clinton's Health Reform and the Turn against Government (New York: W.W. Norton, 1997); Hacker, J. S., The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security (Princeton: Princeton University Press, 1997).Google Scholar
Reinhardt, U. E., “A Social Contract for 21st Century Health Care: Three-Tier Health Care with Bounty Hunting,” Health Economics 5, no. 6 (1996): 479499.3.0.CO;2-N>CrossRefGoogle Scholar
Mechanic, D., “The Rise and Fall of Managed Care,” Journal of Health and Social Behavior 45 (Extra) (2004): 7686; Pegram v. Herdrich, 530 U.S. 211 (2000).Google Scholar
Himmelstein, D. U., Woolhandler, S., Hellander, I., and Wolfe, S. M., “Quality of Care in Investor-Owned vs. Not-for-Profit HMOs,” Journal of the American Medical Association 282, no. 159 (1999): 159163; Tu, H. T. and Reschovsky, J. D. “Assessments of Medical Care by Enrollees in For-Profit and Nonprofit Health Maintenance Organizations,” New England Journal of Medicine 346, no. 17 (2002): 12881293; Landon, B. and Epstein, A. M., “For-Profit and Not-for-Profit Health Plans Participating in Medicaid,” Health Affairs 20, no. 3 (2001): 162171; Consumer's Union, “How Does Your HMO Stack Up?” Consumers Reports 64 (1999): 23; Riley, G. F., Ingber, M. J., and Tudor, C. G., “Disenrollment of Medicare Beneficiaries from HMOs,” Health Affairs 16, no. 5 (1997): 117124.CrossRefGoogle Scholar
Rodwin, M. A., “Backlash as Prelude to Managing Managed Care,” Journal of Health Politics, Policy and Law 24, no. 5 (1999): 11151126; Brown, L. and Eagan, E., “The Paradoxical Politics of Provider Re-empowerment,” Journal of Health Politics, Policy and Law 29, no. 6 2004 10451072; Zelman, W. A. and Berenson, R. A., The Managed Care Blues and How to Cure Them (Washington, D.C.: Georgetown University Press, 1998).CrossRefGoogle Scholar
See Rodwin, , supra note 65.Google Scholar
Rodwin, M. A., “Consumer Protection and Managed Care: The Need for Organized Consumers,” Health Affairs 15, no. 3 (1996): 110123.CrossRefGoogle Scholar
Rodwin, M. A., “Consumer Protection and Managed Care: Issues, Reform Proposals, and Trade-Offs,” Houston Law Review 32, no. 5 (1996): 13191381. A series of articles on managed care regulation appears in a symposium issue of the Seton Law Review vol. 26, no. 3 (1996). For discussions of market failure and managed care regulation see, Korobkin, R., “The Efficiency of Managed Care ‘Patient Protection’ Laws: Incomplete Contracts, Bounded Rationality, and Market Failure,” Cornell Law Review 85, no. 1 (1999): 188; Hall, M. A. and Sloan, F. A., “Market Failures and the Evolution of State Regulation of Managed Care,” Law and Contemporary Problems 65, no. 4 (2002): 169206. For more recent reviews of managed care regulation see, Furrow, B. R., Greaney, T. L., Johnson, S. H., Jost, T. S. and Schwartz, R. L., Health Law, 2nd ed. (Saint Paul, MN: West, 2000) “Regulation of Managed Care,” 501508; Hall, M. A. and Sloan, F. A., “Market Failures and the Evolution of State Regulation of Managed Care,” Law and Contemporary Problems 65, no. 4 (2002): 169206; Altman, S., Reinhardt, U. and Schactman, D., Regulating Managed Care: Theory, Practice, and Future Options (San Francisco: Jossey-Bass Publishers, 1999). For discussion of quality standard regulation, see Brennan, T. A., “The Role of Regulation in Quality Improvement,” The Milbank Quarterly 76, no. 4 (1998): 709732.Google Scholar
Dallek, G. and Pollitz, K., External Review of Health Plan Decisions: An Update (Menlo Park: Family Foundation, 2000). External review laws, however, also had some unintended consequences in terms of diminishing consumer voice. See, Rodwin, M. A., “Patient Appeals as Policy Disputes,” in Hoffmaan, B., Tomes, N., and Grob, R. et al., Impatient Voices: Patients as Policy Actors (New Brunswick, NJ: Rutgers University Press, in press).Google Scholar
See Rodwin, , supra note 69.Google Scholar
Robinson, J. C., “The End of Managed Care,” Journal of the American Medical Association 285, no. 20 (2001): 26222628; Jacobson, P. D., “Who Killed Managed Care? A Policy Whodunit,” St. Louis University Law Journal 47, no. 2 (2003): 365396; Hall, M. A., “The Death of Managed Care: A Regulatory Autopsy,” Journal of Health Politics Policy and Law 30, no. 3 (2005): 427452.CrossRefGoogle Scholar
Rosenthal, M., Landon, B. E., and Normand, S.-L. T. et al., “Pay for Performance in Commercial HMOs,” New England Journal of Medicine 355, no. 18 (2006): 18951902.CrossRefGoogle Scholar
Medicaid Managed Care Enrollment as of December 31, 2008, available at <http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/downloads/08Dec31f.pdf> (last visited May 6, 2010).+(last+visited+May+6,+2010).>Google Scholar
Center for Medicare and Medicaid Services (CMS), Medicare Advantage Program Facts and Figures, January 2009, available at <http://www.ahip.org/content/default.aspx?docid=25733> (last visited May 6, 2010).+(last+visited+May+6,+2010).>Google Scholar
Gold, M., “Private Plans in Medicare: Another Look,” Health Affairs 24, no. 5 (2005): 13021310; Oberlander, J., “Through the Looking Glass: The Politics of the Medicare Prescription Drug, Improvement, and Modernization Act,” Journal of Health Politics, Policy and Law 32, no. 2 (2007): 187718219, at 1820018207.CrossRefGoogle Scholar
Medpac, , Report to the Congress: Improving incentives in the Medicare program, 2009, at Ch. 2, “Accountable Care Organizations,” 3958; Fisher, E. S., McClellan, M. B., and Bertko, J. et al., “Fostering Accountable Health Care: Moving Forward in Medicare,” Health Affairs 28, no. 2 (2009): w219w231.Google Scholar
For a discussion of the globalization of managed care, see Rodwin, M. A., Conflicts of Interest and the Future of Medicine: The United States, France and Japan (New York: Oxford University Press, forthcoming 2010); Weiner, J. P., Famadas, J. C., and Water, H. R., “Managed Care and Private Health Insurance in a Global Context,” Journal of Health Politics, Policy and Law 33, no. 6a (2008): 11071131; Beichl, L., Gunnery, L., and Navarro, J. A., “A Formula for Successfully Competing in Non-U.S. Health Insurance Markets,” Managed Care Quarterly 11, no. 2 (2003): 2228; Gould, B. S., “When Managed Care Doesn't Travel Well: A Case Study of South Africa,” in Wieners, W. W., ed., Global Health Care Markets: A Comprehensive Guide to Regions, Trends, and Opportunities Shaping the International Health Arena (San Francisco: Josey Bass, 2000): at 52–65; Jacobs, A., “Seeing Difference: Market Health Reform in Europe,” Journal of Health Politics, Policy and Law 23, no. 1 (1998): 133; Le Grand, J., “Competition, Cooperation, or Control? Tales from the British National Health Service,” Health Affairs 18, no. 3 (1999): 2739.Google Scholar
World Development Report 1993: Investing in Health, World Bank, Washington, D.C., 1993.Google Scholar
Homedes, N. and Ugalde, A., “Why Neoliberal Health Reforms Have Failed in Latin America,” Health Policy 71, no. 1 (2005): 8396; Iriart, C., Merhy, E. E., and Waitzkin, H., “Managed Care in Latin America: The New Common Sense in Health Policy Reform,” Social Science & Medicine 52, no. 8 (2001): 12431253; Laurell, A. C., “Health Reform in Mexico: The Promotion of Inequality,” International Journal of Health Services 31, no. 2 (2001): 291321; Stocker, K. H. W. and Iriart, C., “The Exportation of Managed Care to Latin America,” New England Journal of Medicine 340, no. 14 (1999): 11311136.CrossRefGoogle Scholar
See Homedes, and Ugalde, , supra note 79.Google Scholar
Laurel, A. C., “Health System Reform in Mexico: A Critical Review,” International Journal of Health Services 37, no. 3 (2007): 515535, at 520.CrossRefGoogle Scholar
Rodwin, V. G., and Le Pen, C., “Health Care Reform in France – The Birth of State-Led Managed Care,” New England Journal of Medicine 351, no. 22 (2004): 22592262.CrossRefGoogle Scholar
See Rodwin, , supra note 77.Google Scholar
Okamoto, E. and Kozo, T., Public Health of Japan, 2007 (Tokyo: Japan Public Health Association, 2008): at 51–53, and correspondence with Okamoto, E., September, 2002.Google Scholar
See id. (Okamoto, and Kozo, ), at 46.Google Scholar