CHAPTER

Health Care Economics

19
CHAPTER OBJECTIVES

After careful study of this chapter, you should be able to:

* Recognize the importance of health care

economics. * Identify the various types of health
care institutions. * Define the most common health
care payment
methods.
Characterize the significance of
managed care.
* Identify the purpose of cost containment
measures. * Explain the importance of resource
management.

KEY TERMS

co-insurance

co-pay

deductible

diagnostic related
groups
(DRGs)
direct
payment
flexible spending
account
(FSA)
gatekeep
er
government institution government plan health care cost
containment

health maintenance
orga- nization (HMO)
plan health savings
account
(HSA)
 in-network
provider
managed
care
Medicaid

Medicare
out-of-network provider
point-of-service (POS) plan
preferred
provider
organization (PPO) plan premium
private insurance
proprietary
institution
prospective
payment
system
resource utilization
TRICARE
utilization review

voluntary
nonprofit
institution

The costs of health care are a growing concern for all Americans,
consumers and providers alike. Rising drug, technology, and
professional costs, along with an aging population, are major factors
contributing to rising costs.

311
312 CHAPTER 19 Health Care Economics

There's an ongoing discussion in the U.S. about what

Patients,
measures are needed to rein in the cost of health care.
health care providers, insurance carriers, employers,
and politicians are all active participants in this
continuing debate. Measures designed to lower health
care costs, or health care cost containment, aim to create
an affordable health care system for all Americans.
 All health care professionals should understand the
basic economic aspects of health care and how
these impact patients. This helps health care
providers stay aware of how finances affect each
patient's experience. Health care workers can then
make conscious and prac- tical decisions that
promote affordable, quality care for every patient.
ZOOM IN

The Rise in U.S. Health Care Costs

According to the Centers for Medicare and

Medicaid Services (CMS), U.S. health care spending
for the ten- year period from 2008-2018 is projected to
grow by 6.2 percent annually. This is 2.1 percent
faster than the country's average annual growth in
gross domestic product (GDP)-the value of all
goods and services pro- duced in the U.S. each
year. By 2018, CMM projects that health care
spending will reach $4.4 trillion- roughly 20.3 percent
of the nation's GDP.

Many Americans experience first-hand the rising cost

of health care.

DIFFERENCES AMONG HEALTH

CARE INSTITUTIONS

As discussed in Chapter 1, "Today's Health Care

System," there are many different kinds of health care
facilities- from hospitals to assisted-living facilities to
rehabilitation centers. These facilities can be grouped
into three catego- ries, depending on how they are
funded. The three cate- gories (voluntary
nonprofit institutions, proprietary insti- tutions,
and government institutions) will be described later in
 this section.

Regardless of their funding, many of these

facilities provide a wide range of community
services. These ser- vices may include:
⚫ emergency room treatment
community health education classes and
materials ⚫ health screening services
clinical services

⚫ medical education for physicians, nurses, and

other
health
professionals
In 2006, the U.S. infant mortality rate was ranked 33rd in the world by the United Nations.

U.S. health care costs are among the highest in the world, averaging just over $2,600 per person in 2006. However,
these higher costs don't always mean bet- ter care. For
example, the United Nations ranked the U.S. infant
mortality rate at 33rd in the world in 2006. The infant
mortality rate is commonly used to assess a country's
overall level of health. The U.S. infant mortal- ity rate
was higher than that of many other developed nations
with lower health care costs, including the United
Kingdom, France, and Germany.

financial contributions to community organizations

coordination of events and donations-such as food,
clothing, and meeting room space-for
community organizations

Voluntary Nonprofit Institutions

A voluntary nonprofit institution is a community facil- ity that receives federal, state, and local tax
exemptions in exchange for providing a
community benefit, such as services to Medicaid
patients and those who are unable to pay. These
institutions typically receive other advantages,

qualify
such as donations that are tax-deductible for donors. To
for federal tax-exempt status, an institution must
show that it is operated for a charitable purpose.
No part of the institution's net earnings may
benefit private share- holders or individuals.
 Some hospitals are voluntarily nonprofit, while others are
private, for- profit institutions.

Proprietary Institutions
A proprietary institution is a for-profit health care
facility usually owned by a corporation. Health care
corporations. often control a chain of facilities that
include hospitals, nurs- ing homes, outpatient facilities,
and other health care facilities in several states. These
institutions are run just like any other corporation and
must pay local, state, and federal taxes.

Government Institutions
CHAPTER 19 Health Care Economics 313

Military treatment facilities

⚫ Veterans Affairs (VA)
hospitals
Public or government-funded hospitals ⚫ State mental hospitals

A government institution is a public health care

facil- ity that receives most of its funding from local,
state, or federal sources. These facilities include:
• State rehabilitation facilities
 CHECK POINT

1 List major factors causing a rise in health

care costs.
2 What are some major differences among the
three types
of health care institutions (voluntary nonprofit, proprietary, and government) found in the U.S.?

HEALTH CARE PAYMENT METHODS

In the U.S., health care is paid for by one or more of the following three methods:
⚫ private insurance
direct payment government plans
Most patients rely on employer-provided health
insurance coverage to pay for most of their medical
bills. However, a growing number of Americans pay
for their health care costs directly, while others
rely on government assistance to cover their
medical payments.
Whether health care is provided at a voluntary non- profit, proprietary, or government institution, the facil- ity must
still seek some type of payment for services ren-
dered. Health care professionals should be
familiar with the basics of each health care payment
method.

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Some health care facilities receive most of their

funding from the govern-
ment.
Health care payment methods vary, though many American rely on health insurance rather than direct pay.
 Private Insurance

Private insurance in the U.S. is primarily an employ-

ment-based health insurance system. This means that
most Americans obtain health insurance through their
314 CHAPTER 19 | Health Care
Economics

place of employment. Because employers (or other

orga- nizations such as unions or professional
associations) buy insurance for a group of people,
they can get better rates from insurance companies
than an individual can. Insur- ance companies benefit
from offering this group insur- ance because they
collect payments from everyone in the group, even
though not all people in the group may incur health care
expenses covered by the insurance plan.
To lower their own costs, many companies are
placing more of the financial responsibility on the
insured (the employees covered under the health
insurance policy) in the form of premiums,
deductibles, co-insurance, and co-pays. A
premium is the monthly amount paid to an
insurance company for health insurance coverage. In
the past, this amount was often paid by employers as
part of an employee's benefits package. Today,
however, most employees are responsible for paying a
portion, and some- times all, of their monthly premium
through pre-tax pay- roll deductions. In exchange for
this monthly premium, the insurance company pays for
eligible health care expenses.
A deductible is the money a person pays before
the insurance policy provides benefits. For example,
if an
Health Benefits Claim Form
CENTIFICATION
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For patients with private health insurance, claims may go directly from the provider to the insurance company.

insured person (the insured) has a $1,500

deductible for hospital or surgical insurance
coverage, the insured must pay the hospital for
the first $1,500 of hospital costs. After the insured
has "met the deductible," the insurance com- pany will
pay the remainder of the costs in accordance with the
terms of the insurance policy. Deductibles are
 ZOOM IN

A Move Toward Consumer-Driven Health Care

Although employer-provided health insurance has

been a tradition in the U.S. health care system, many
economists and health care experts agree that
Ameri- cans can no longer depend on this approach
to meet their medical costs. In an attempt to cut costs and
boost profits, many companies are paying less of the
cost for employee health insurance coverage. Other
businesses have eliminated health insurance benefits
altogether. These trends, coupled with rising health
care costs, are putting a heavy financial burden on
American health
care consumers.

Many experts believe that giving individuals more

con- trol over their own health care funds will reduce
health care-related spending. One way to do this is
through health-related savings accounts, which
provide consumers with the means to control their
own health care spending.
A flexible spending account (FSA) is offered
through an employer and is usually paired with a
tra- ditional health insurance policy. It is the most
common medical savings account option. Money is
put into an FSA through payroll deductions,
before it is taxed. Funds can be withdrawn for
qualified medical expenses, such as prescriptions,
co-payments, or medical services not covered by
the insurance policy. However, employees need to
plan carefully before deciding how much money
to put into an FSA, because any funds remaining at
the end of the year are forfeited. The plan is called a
flexible "spending" account because the money must
be spent each year.
A health savings account (HSA) is commonly paired with a high-deductible health insurance plan-a plan that offers
low monthly premiums, but requires the in- sured person
to pay a high deductible. An HSA may be offered
through an employer's benefits program or ar-
ranged by an individual. People pay for their qualified
medical care using tax-free HSA dollars, until they meet
their deductible. Once the deductible is met, the health
insurance company pays for most or all medical
costs for the remainder of the year. Unlike an FSA, any
funds re- maining in an HSA are rolled over at the
end of the year. This plan is called a health
"savings" account because leftover funds can be
saved for future use.
Money accumulated in an HSA can be invested and used to pay for qualified medical expenses later in life.
When a person reaches age 65 (or becomes
disabled), this money can be withdrawn for any
purpose without penalty. Individuals who have high-
deductible insurance policies and HSA accounts
 often are more involved in their health care
decisions. They may be less likely to make
unnecessary doctor visits or undergo excessive
medical tests, because payment for those services
comes out of their savings accounts.

one way for an insured person to control health insurance

costs health insurance policies that have high
deduct- ibles generally have lower monthly
premiums.
Once the insurance plan's deductible has been met,
the patient may still have to pay a portion of the medical
costs if the insurance plan is a co-insurance plan. Co-
insurance (which stands for cooperative
insurance) is the term used to describe plans that
require the insured to share a por- tion of the costs
for health care services (usually 10 to 30 percent).
The primary purpose of co-insurance is to lower
monthly premiums.
Many health insurance plans also require
patients to pay a flat fee, called a co-pay, each
time they receive a health care service. For example,
an insurance company may require patients to pay
$25 for each physician visit or $10 for each
prescription filled. Co-pays are paid directly to the
service provider, such as a physician or
pharmacy.
There are a variety of private insurance plans.
Depend- ing on their plan, people often must
choose a provider

NEWSREEL

Health Care Reform in the U.S.

The U.S. currently spends over $7,000 per person

on health care, nearly twice as much as any other industri-
alized nation. Yet in 2009, nearly 47 million Americans
didn't have health care coverage, and millions more
had inadequate coverage. When President Obama
took of- fice in 2009, he called the U.S. health care
system one of the nation's "greatest challenges" and
pledged to reduce costs while expanding coverage.
Since then, Congress has taken steps toward health
care reform, beginning with the passage of the
Affordable Care Act that was signed into law on March
23, 2010.
This law puts into place health insurance reforms
that are designed to make insurance companies
more ac- countable. The reforms also are intended to lower
 health care costs, guarantee more health care choices, and
im- prove the quality of health care for all Americans.
The Act will not be implemented all at once. Portions
of the law have already taken effect, such as giving
tax credits to small businesses to help them provide
health insurance to their workers. However, other,
more significant changes will not be put into effect
until 2014 and beyond.
One of those significant changes is the formation of
Exchanges competitive insurance marketplaces
where individuals and small businesses can buy
affordable, quality health insurance plans. Starting in
2014, if an em- ployer doesn't offer insurance,
employees will be able to buy insurance directly
through an exchange. Exchanges will offer a choice of
health plans that meet certain ben- efit and cost standards.
CHAPTER 19 Health Care Economics 315

network and other managed care options to reduce their premiums and health care costs. (These different plans. are
discussed later in this chapter.) Because health insur-
ance plans differ greatly, health care professionals
need. to know which services a patient is eligible
for before the services are provided.

Direct Payment
When patients pay for their health care with their
own money, this is known as direct payment. People use
direct payment when private insurance doesn't
cover all their health care costs, when they don't have
private insur- ance, or when they don't qualify for a
government plan.
Some health care economists believe that when people are responsible for paying their own medical
expenses, they're more likely to make health care
decisions that take costs into account. For example,
if people know that they will have to pay all of
their primary physician costs

As of this writing, one aspect of health care reform that Congress continues to debate is the "public option."
While the exact definition changes with each debate,
the public option is broadly defined as a government-
sponsored health insurance plan that would
compete with private insurance plans in the
exchanges. The goal of a public option is to provide
more competition and choice, especially in those
places where only a few insurers-and sometimes
only one-dominate the marketplace. Indi- viduals and
businesses would not be required to purchase or use
 the public option, but could continue to purchase
insurance through private insurers.
In order to compete fairly with private insurers, the public option would be required to operate on a "level
playing field" with other insurers. This means that it
would have to meet the same benefit requirements
and follow the same rules and regulations as private
plans. The public option also would have to be
financially self- sustaining. In other words, it would
not be supported by taxpayer dollars.
Many people wonder how a public option would be able to compete successfully with private insurers. Sup-
porters of the public option believe it would be more
cost effective than private plans because it would not
have to make a profit, would have lower
administrative costs, and would not have excessive
executive salaries. These cost savings would make
public option insurance plans more affordable for
consumers. This, in turn, would pres- sure private
insurers to become more efficient and lower premiums to
attract and keep customers.
316 CHAPTER 19 Health Care Economics

themselves, they're more likely to shop around and

find a care provider who charges less. This
"shopping around" by health care consumers
creates competition that drives down health care
prices.
On the other hand, placing more of the
responsibility for health care costs on individuals can
results. According to a study
have devastating
published in the August 2009 issue of The
American Journal of Medicine, 62 percent of
all bankruptcies filed in 2007 were linked to
medical costs, and 75 percent of those individuals had
health insurance.

Government Plans

A government plan is a health care plan funded

by a government agency. Government plans are
available for active military personnel and their
dependents. Veterans are also covered under
government health care plans. However, the two
main government-funded health care programs are
Medicaid and Medicare, which provide health care
coverage to low-income and older Americans. In
2007, nearly 28 percent of Americans were
covered under Medicare or Medicaid.

Medicare
The federally-funded health care program for
older Americans is called Medicare. This program
was estab- lished by amendments to the Social
Security Act in 1965 to provide health care coverage
for Americans aged 65 or older, regardless of
income or wealth. Within a decade, nearly all
eligible citizens had Medicare insurance for
hospital care, extended care, and home health
care.
Over the years, several amendments were made to
the Medicare program. In 1972, Medicare was
expanded to include permanently disabled
workers who qualify for Social Security, as well as
their dependents.

of Your Medicare Par

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Medicare is a federally-funded health care program

established in 1965 to provide coverage for Americans
aged 65 or older.
In an effort to control rising health care costs, Medi- care converted to a prospective payment system in
1983. This system pays the provider a fixed
amount that is based on the medical diagnosis or
specific procedure, rather than on the actual cost
of hospitalization or care. If the actual cost for care
is greater than the fixed amount, the provider must
absorb the additional expense.
Most Americans aren't required to pay a monthly pre- mium for Medicare Part A, a program that covers
most inpatient care costs. The premium for this
program has already been paid through
payroll taxes. Medicare Part B, which is
voluntary, charges a monthly premium. Medi- care
Part B covers most outpatient costs, such as
physician visits, medications, and home health
services. Because Medicare doesn't cover the total
cost of all services, peo- ple often choose to
purchase a supplemental insurance policy offered
by a private insurance company.
Two additional plan types are offered to supplement Medicare, both with additional monthly premiums.
 Medicare Advantage Plans are Medicare-
approved plans offered by private insurance
companies. Sometimes called Medicare Part C,
these plans provide coverage for Part A and Part
B services, but generally have extra benefits and
lower co-payments than the regular Medicare program.
Prescription drug coverage is available under
Medicare Part D.

Medicaid

A government program that offers health insurance

to many low-income and disabled people is
known as Med- icaid. Like Medicare, this program
was established in 1965 as part of the Social
Security Act. Medicaid provides assistance for
people of any age who have low incomes. The
program also offers health coverage to blind,
older, and disabled citizens who receive
Supplemental Security Income (SSI) benefits.
Prior to 1996, people who received Aid to Families with Dependent Children (AFDC) were also covered under
Medicaid. The AFDC program was replaced by
the Per- sonal Responsibility and Work
Opportunity Reconcilia- tion Act (PRWORA) of 1996.
This act provides states with block grants that can be
used to provide cash and services to low-income
families with children. Health care coverage under
PRWORA depends on individual state regulations.

Government Plans for Military Personnel

Government health care plans are also available for
mili- tary personnel and their families. The U.S.
Department of Defense administers TRICARE, a
system that pro- vides medical coverage for active and
retired service per- sonnel and their dependents.

New Government Programs

The State Children's Health Insurance Program

(SCHIP), established in 1997, provided states with
matching funds to help expand health care
coverage to over 6 million uninsured children.
This program became the center of a national
debate when it was set to expire in 2007.
Legislation that would have expanded the
program by nearly $35 billion passed the House and
Senate, but was vetoed by former President George W.
Bush. However, in 2009, the Children's Health
Insurance Program Reau- thorization Act
 (CHIRPA) was passed by Congress and
signed into law by President Barack Obama.
CHIRPA added $33 billion in federal funds for
children's coverage through 2013.

CHECK POINT

3 How is health care paid for in the

U.S.?
4 How do most Americans obtain health insurance?

MANAGED CARE

Health care costs in the U.S. have grown at nearly twice

the rate of inflation. The U.S. spends more for health
care services than any other industrialized nation,
both as a percentage of gross domestic product
(GDP) and per person. One response to the rapid
escalation in health care costs is managed care,
which puts health care providers in the position
of managing a patient's use of health care. There
are many types of managed care, but most plans fall
within one of the following three cat- egories:
Health maintenance organization (HMO) plan. This plan
provides coverage only if the care is deliv-
ered by a member of its hospital, physician, or phar-
macy panel.
• Preferred provider organization (PPO) plan. This
plan allows patients to receive care from a non-
plan provider, but requires them to pay a higher
out-of- pocket price if they do so.
• Point-of-service (POS) plan. This is a physician-
co- ordinated plan that combines characteristics of
both HMO and PPO plans.

All three types of managed care plans have contracts

with health care providers, like doctors and hospitals,
with predetermined rates for services. Providers
in the plan are called in-network providers.
Providers who are not in the plan are called out-
of-network providers. Typically, the cost of care
from an in-network provider is less than from an
out-of-network provider.
CHAPTER 19 Health Care Economics 317

Managed care plans have a few important characteris- tics that make them different from other forms
of private insurance:
They consist of a select group of primary care
providers. They provide a broad range of
 services, generally em- phasizing primary and
preventive care. They eliminate duplicate
services. They encourage cost containment.
They provide a profit for both health care
providers and insurance companies.
They include utilization review.

Utilization review is a process in which an insurer reviews decisions by physicians and other providers
about how much care to provide. In many plans,
the primary care provider serves as a gatekeeper.
A gatekeeper is a physician who not only delivers
primary care services but also makes referrals for
specialty care.
Managed care plans generally put more emphasis on preventive care. A study published in The American
Jour- nal of Managed Care found that managed
care patients were more likely to receive
preventive services, including blood pressure checks,
cholesterol screenings, and mammograms.

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Family Care Associates
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PREVIOUS STATEMENT
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All three types of managed care plans have contracts with

health care providers, like doctors and hospitals, with
predetermined rates for services.
PAY

318 CHAPTER 19 Health Care Economics

However, the study also found that health care

profession- als spent on average two minutes less
with managed care patients than other patients.
Nonetheless, managed care remains the leading
form of health care coverage for Amer- icans,
with just over 50 percent of all insurance coverage
provided by managed care plans.

CHECK POINT

5 What is managed
care?
6 How do managed care plans differ from other
forms of
private
insurance?

COST CONTAINMENT MEASURES

A driving force behind the effort to contain health care

costs is the diagnostic related group (DRG) classifica- tion
system, used by Medicare and Medicaid to determine
payment for health services. Patients with similar medical
conditions are assigned to a DRG. Payment amounts
 for the DRG are based on the average costs for patients in
the group. Patients are assigned to a DRG based
on their diagnosis, surgical procedures, age, and
other information. Hospitals provide this
information on their bills, and Medi- care uses this
information to decide how much to pay the hospitals.
With this type of payment system, patients' diag-
noses, treatments, surgical procedures, and any
follow-up care are paid in standard fees, regardless of the
actual cost of care. For example, all hospitals are paid
the same for patients who have their gallbladder
removed. The results of DRGs have been dramatic. If
the hospital incurs greater cost for the care of the
patient than provided by the DRG, the hospital
must bear the cost. If the hospital provides care to
the patient for less than the DRG payment, the
hospital still receives the full payment. As a result,
DRGS offer an incentive for hospitals to operate more
efficiently.
Since the introduction of DRGs as part of Medicare and Medicaid, other health care plans have
begun adopting DRGs as a method of payment.
Shorter hospital stays, more outpatient services, and
a focus on early intervention and prevention services are
just a few of the results of DRGs.

UTILIZING RESOURCES EFFICIENTLY

Health care facilities, both for-profit and nonprofit, are businesses and must operate efficiently to continue to
exist. As a result, they expect the health care
professionals they employ to make efforts to cut
costs. All health care work- ers need to ask
themselves how they can best use health care resources.
This is called resource utilization.
One way professionals can better use resources is through conscientious time management. For example,
rather than allowing a patient to wait idly in an empty
exam room, it is more efficient for a health
professional, such as a physician's assistant, to
begin a basic patient evaluation before the
primary care provider becomes available.
Information technology is another resource utiliza- tion tool used by health care professionals. Electronic
documentation of patient records and other files not
only reduces the amount of time a provider
spends searching for and relaying information,
but it also reduces the risk of human error.
Prescription refills sent electronically save health care
workers from having to make multiple phone calls to
pharmacies. Test results are analyzed more
quickly and accurately by a computer.
 CHECK POINT

7 What are DRGs? How do they affect the amount paid

to
providers for health care
services?
8 Why should health care workers practice resource
utiliza-
tion?

Chapter Wrap-Up

Don't forget to visit the Point companion website for additional

study resources!

CHAPTER HIGHLIGHTS

The U.S. health care system is composed of voluntary nonprofit, proprietary,

and government institutions. Voluntary nonprofit institutions must provide
community benefits in order to re- tain their nonprofit status and tax
exemption. Proprietary institutions are for-profit health care facilities, usually
owned by corporations. Government institutions receive most of their fund- ing
from local, state, or federal agencies.
• The most common health care payment methods in the U.S. are private insurance,
direct pay- ment, and government plans. Most private insurance in the U.S. is
obtained through employ- ers. Medicare and Medicaid are the two main government
plans.
• Managed care provides coverage for health care through a select group of
providers, with pre- determined rates for services, and is usually less costly than
traditional insurance coverage sys- tems. Health maintenance organizations
(HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans
are all managed care plans.
• Diagnostic related groups (DRGs) are a classification system used by Medicare and
Medicaid to determine payment for health services based on diagnosis, regardless
of the actual cost of
care.
• Resource utilization tools that can help health care professionals cut costs include
careful time management and information technology.

REVIEW QUESTIONS

Matching

Measures to control health care costs and create an affordable health care system. A for-
profit health care facility, usually owned by a corporation.
1.

2.

3.
A type of insurance plan that requires the insured to share a portion
 of the costs for health care services even after a deductible has been met.
4.

Provides health care coverage to active and retired military

personnel and their dependents.
5.
A fixed amount that is predetermined by the medical diagnosis or
specific proce- dure.
a. co-insurance b. health care cost containment c. TRICARE d. proprietary
institution e. prospective payment

Multiple Choice
6. Medicare, Medicaid, and TRICARE are all
a. private insurance
plans
b. managed care
plans
c. government plans
d. direct payment plans

7. The monthly amount paid to a private insurance company for health insurance
coverage.
a. deductible
b. premium
c. co-insurance

d. co-payment

319
320 CHAPTER 19 Health Care Economics

8. A flat fee paid by the patient directly to the service provider each time the
patient receives a
health care service.
a. deductible
b. premium
c. co-insurance

d. co-pay

9. The money a patient must pay before an insurance policy

provides benefits.
a. deductible
b. premium
c. co-insurance
d. co-pay

10. People use this type of payment when their insurance doesn't cover all
health care costs,
when they don't have health insurance, or when they don't qualify for a
 government plan.
a. prospective payment
b. direct
payment

Completion
c. payroll deduction
d. co-insurance

11. In return for federal, state, and local tax

exemptions,
community benefits.
institutions must provide

12. The federally-funded health care program designed for older

Americans is called
13. The system used by Medicare and Medicaid to determine payment for health
services based
on diagnosis is
the
classification system.
14. The government program that provides health insurance for low-income
and disabled people
is known as

15. A
system provides coverage for health care through a
select
group of providers, with predetermined rates for
services.

Short Answer

16. What types of health care providers are in the category of government
institutions?

17. Why do health care professionals need to understand the economics of

health care?

18. Name two resource utilization tools that can help health care professionals
cut costs.

19. Insurance in the U.S. is primarily an employment-based health insurance system.

What does
this mean?

20. Briefly explain the differences between HMO, PPO, and POS managed
care plans.