Managed care in the Twin Cities : what can we and

Minneapolis/ St. Paul, because of its history of health maintenance organization develop ment and active employer participation in the health care arena, is often cited as a community in which managed competition has been tested to some degree. This paper reviews the historical development of the Twin Cities health care market and summarizes findings from past studies of this market. It also describes the recent consolidation of providers in the Twin Cities, as well as the activities of large purchasing coalitions. Finally, it assesses the elements of the Twin Cities experience that seem most relevant to managed competition-based health care reform proposals. Managed competition was the cornerstone of the Clinton administration’s plan for health care reform and served as the basis for other legislative reform proposals as well. The essential elements of this approach include health plans competing for enrollees, with large purchasers or purchasing coalitions “managing” the competitive process. The Twin Cities market (Minneapolis/ St. Paul, Minnesota), because of its history of health maintenance organization (HMO) development and active employer participation in the health care arena, is often cited as an area in which managed competition has been tested to some degree. In this paper we review the historical development of the Twin Cities health care market and the results of past studies of this market. We describe recent developments in the Twin Cities, including the activities of large purchasers and the consolidation of providers. A final section discusses the lessons that can be drawn from the Twin Cities experience, especially those relevant to managed competition. Impact Of HMO Growth In The Twin Cities The health care delivery system in the Twin Cities is known nationally for its role in the development of what many believe are the building blocks of managed competition: HMOs (Exhibit 1). From 1971 to 1978 HMO enrollment in the Twin Cities grew at an annual rate of 27 percent. Enrollment continued to grow during the 1980s, reaching 50 percent of the population by the end of the decade. During these years HMOs in the Twin Cities encompassed a variety of organizational forms and sponsorship arrangements, and by the early 1980s most physicians were affiliated with one or more of these health plans. The 1980s saw important changes in Twin Cities HMOs and their relationships with providers, including the development of new products, such as preferred provider organizations (PPOs) and the institution of more aggressive management strategies, such as concentrating patients at lower-cost hospitals. As HMOs gained market share and introduced stronger cost control measures, their influence on the structure of the Twin Cities health care delivery system also increased. HMOs and hospitals. One of the most contentious issues concerning HMO development during the late 1970s and early to mid-1980s was its on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 116 HEALTH AFFAIRS | Summer 1995 Exhibit 1 Health Maintenance Organizations (HMOs) In The Twin Cities HMO Parent, owner, or Headquarters manager Year 1993 o p en ed en r o l lm en t Hi sto ry / st a tu s Blue Plus Eagan Blue Cross and Blue Shield of Minnesota 1974 67,411 Changed name from HMO Minnesota in 1988; absorbed Coordinated Health Care HMO in 1988; affiliate Minnesota Health Plans, Inc., merged into Blue Plus, effective 3 1 December 1990 Group Health Minneapolis Group 1957 303,573 Includes GroupCare, nonHealth, federally qualified HMO; Inc. merged with MedCenters Health Plan to form HealthPartners in 1992 MedCenters St. Louis Park Aetna Health Plans 1973 214,436 Formed by merger of MedCenter Health Plan and Nicollet-Eitel Plan in 1983; merged with Group Health in 1992 Medica Medica Choice Minnetonka United Health Care 1975 479,369 Formerly known as Physicians Health Plan (PHP); combined with Share Health Plan to form Medica, effective 1 January 1991 Medica Primary 1973 Formerly known as Share Health Plan Metropolitan Minneapolis Health Plan NWNL St Paul Health Network Hennepin 1983 32,719 County Bureau of Health Northwestern 1984 32,875 National Life WWNL) Insurance Comuany Created for Medicaid demonstration project and Voluntary AFDC Managed Care Program Founded as Senior Health Plan; acquired and renamed by NWNL in 1987 UCare Minneapolis University of 1989 25,416 Created for Medicaid Minnesota, demonstration project Department of Family Practice Sources: Citizens League Research, Minnesota Managed Care Review, 1992; and A. Baumgarten, Minnesota Managed Care Review, 1994. Note: Group Health and MedCenters enrollment figures do not include Business Health Care Action Group employee enrollees. on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom MANAGED CARE IN TWIN CITIES 117 impact on Twin Cities hospitals. By the end of the 1980s four major multihospital systems had been created through mergers and buyouts. Some hospital administrators believed that multihospital organizations could negotiate prices with HMOs more effectively and offer broader geographic coverage for HMO enrollees. They argued that hospital consolidation was the direct result of the growing competitiveness of the Twin Cities hospital market created largely by HMOs. However, initial studies of the effect of HMOs on Twin Cities hospitals did not find compelling evidence that competition among HMOs had contained hospital costs. By 1986, however, the pattern of HMO/ hospital relationships had begun to change. Roger Feldman and colleagues found that HMOs in four large metropolitan areas (including the Twin Cities), especially staffand network-model HMOs, were beginning to concentrate their patients at certain hospitals and that price played an important part, not so much in the HMOs’ choice to affiliate with a particular hospital, but in the volume of services demanded from the hospital. The estimated price elasticity of demand for admissions in HMO-affiliated hospitals was -3.0, indicating a considerable degree of price-sensitivity, with a 3 percent reduction in admissions associated with a 1 percent increase in price. Individual practice associations (IPAs) were not found to exhibit the same degree of price-sensitivity. The estimated price elasticity of demand for IPAs was -1.0. During the 1980s Twin Cities hospitals faced declining discharges and lengths-of-stay across virtually all types of services. Even among the service groups that had some increase in discharges (for example, cardiology, psychiatry, obstetrics, and newborns), lengths-of-stay fell. Although part of the declining use of inpatient resources mirrored a national trend, Bryan Dowd estimated that 33-85 percent of the decline in hospital admissions in the Twin Cities from 1977 to 1982 could be attributed to HMOS.6 The estimate was found to depend crucially on the amount of credit that HMOs were given for reducing lengths-of-stay in the non-HMO sector. The effect of HMOs on lengths of inpatient hospital stay provides an interesting example of the refinement of health plans’ resource management techniques. In early studies of HMOs, HMO membership was associated with a 40 percent reduction in hospital admissions but no reduction in length-of-stay. However, by the mid-1980s Dowd and colleagues found that enrollees in group-practice HMOs in the Twin Cities had significantly shorter lengths-of-stay than commercially insured patients had in five of seven diagnostic groups examined, while enrollees in IPAs had significantly shorter lengths-of-stay in three of these groups. They suggested that reductions in admissions were easier for Twin Cities health plans to achieve than were reductions in length-of-stay, since reduced admissions can occur simply if treatment is switched to an outpatient setting. Length-of-stay reducon O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 118 HEALTH AFFAIRS | Summer 1995 tions, however, involve direct intervention in physicians’ on-site treatment decisions. Thus, it is not surprising that the initial focus of HMOs was on reducing admissions. Once HMOs reduced admissions, however, the competitive advantage to be gained by reducing length-of-stay made that task, although more difficult, worth pursuing. HMOs and consumer choice. During the 1980s some policy analysts argued that high-risk, fee-for-service enrollees were more likely to have a long-standing relationship with their fee-for-service physicians and, therefore, were less likely to join a staffor group-model HMO. Employers in the Twin Cities who offered their employees a choice of HMOs and a fee-forservice plan sometimes saw their total health insurance costs increase as the relatively healthy employees left the experience-rated, fee-for-service plan to join HMOs. 10 However, when employers offered a choice among managed care plans, employees were quite sensitive to out-of-pocket premium differentials. Feldman and colleagues studied choice of health plans by employees in seventeen large Twin Cities firms in 1984. The elasticities they reported were considerably higher than those found in previous studies, as large as -8.6 for choice among single-coverage plans. This means that a 1 percent increase in the out-of-pocket premium differential between two plans reduces the enrollment share of the higher-cost plan by 8.6 percent. Although the HMOs’ incentive to cut prices to consumers was limited by prevailing employer premium contribution methods under which employers typically contributed more toward the premiums of higher-price plans, cost-cutting incentives for HMOs were not similarly impaired. Health plans’ cost-cutting efforts precipitated a shift from relatively close collaborative relationships between plans and providers to a distinct division between financing and service delivery functions. The change was sometimes slow and subtle, but at times it was abrupt and contentious and played out on the front pages of the local press. For example, Physicians Health Plan, started by physicians for physicians, experienced a bitter dispute between physicians and the health plan’s management over fees and administrative practices. 12 The same fate befell MedCenters Health Plan and its founding group, the Park-Nicollet Clinic. Changes in the relations between health plans and providers in the latter part of the 1980s appear to have been driven in part by consumer preferences, as revealed in their choice of health plans. Factors such as coverage, clinic locations, and out-of-pocket premiums often outweighed consumers’ loyalty to specific providers. Since premiums were an important determinant of plan choice, even small out-of-pocket differences among plans produced consumer pressure on plans to restrain premium increases. That pressure eventually was transmitted to providers in contract negotiations. HMOs, access, and health outcomes. Some analysts have expressed on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom MANAGED CARE IN TWIN CITIES 119 concern that competition among capitated health plans for enrollees, and the pressure on premiums that it creates, could have a negative effect on access to services and patient outcomes. Three studies using data from the mid-1980s compared the health outcomes of subgroups of Medicare or Medicaid beneficiaries in Twin Cities HMOs with those of beneficiaries receiving care from providers under normal arrangements. One study examined the difference in physical functioning and perceived general health status between Medicare beneficiaries enrolled in HMOs and those in traditional Medicare. This study found no significant difference in predicted health status, as measured by physical functioning, between the two groups. However, there was a difference in perceived general health status: Those enrolled in HMOs reported a significantly higher status. For a subgroup of lower-income enrollees, no significant differences were found. A second study, by Nicole Lurie and colleagues, compared health and functional status measures of noninstitutionalized elderly Medicaid recipients randomly assigned to prepaid plans and traditional fee-for-service Medicaid. The analysis found no significant difference between the two groups in number of deaths or in any of the listed outcome measures, thus providing no evidence, in the short term, of harmful effects of enrolling elderly Medicaid patients in Twin Cities HMOs. In a third study, Lurie and colleagues examined the effect of HMO enrollment on chronically mentally ill Medicaid recipients, using a similar research design. Here, too, no significant differences were found in general health or mental health status between beneficiaries in traditional Medicaid and those in HMOs. Access to services and use of services by the same group of chronically mentally ill Medicaid recipients also were analyzed. There were no statistically significant differences between HMO enrollees and fee-for-service Medicaid beneficiaries’ access to either physical or mental health care, nor were there significant differences in use of inpatient or outpatient services for HMO enrollees. In particular, there was no statistically significant evidence that Medicaid HMO enrollees with severe mental illness used community-based treatment programs differently than did beneficiaries in fee-for-service Medicaid. However, there was evidence that the HMOs reimbursed programs at a lower percentage of charges than did fee-for-service Medicaid. HMOs and health care spending. Although it is widely believed that overall health care costs in the Twin Cities are relatively low, data are not ‘available to test this hypothesis in a rigorous manner. This would require comparable data over time on insurance premiums and out-of-pocket expenses for residents of the Twin Cities and other U.S. metropolitan areas, adjusted for differences in level of benefits and demographic characteristics. Lacking these data, comparisons of the Twin Cities with other metro areas tend to focus on different components of costs, expenditures, and prices. on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 120 HEALTH AFFAIRS | Summer 1995 Surveys by health benefits consulting firms report that Twin Cities costs and premiums are below national averages, but the samples on which these studies were based are not random, nor are the measures of costs comprehensive.” The medical Consumer Price Index (CPI) for the Twin Cities consistently tracks below other communities, while the overall CPI is about the same as the national average. With respect to inpatient care, Minnesota as a whole has fewer admissions and emergency room visits than the national average, as well as shorter lengths-of-stay. Consistent with the results on private-sector employees, data from the Health Care Financing Administration (HCFA) suggest that spending for fee-for-service Medicare beneficiaries in the Twin Cities is low, relative to the national average and expenditures in other major metropolitan areas. Medicare costs in the Twin Cities have not always been low, however. In 1974 ageand sex-adjusted reimbursements were 28 percent higher in the Twin Cities than the national average. Most of the higher cost was due to Medicare Part A (hospital) costs, which were 35 percent higher, as opposed to Medicare Part B (physician) costs, which were only 8 percent higher. By 1982, however, these costs were only 3 percent higher in the Twin Cities than the national average, with Part A costs 10 percent higher and Part B costs 14 percent lower. In contrast to these results, the Physician Payment Review Commission (PPRC) reported that Minnesota as a whole had adjusted per capita health care expenditures only 1 percent below the national average in 1991 . While the weight of available evidence suggests that health care costs probably are lower for Twin Cities residents than for residents of most other large metropolitan areas, it is not clear to what extent this can be attributed to the growth of HMOs and managed competition in the Twin Cities. Unfortunately, the data simply do not exist to construct comprehensive, comparable measures of health care costs and expenditures over time in different communities. Even were such data available, obtaining accurate estimates of the incremental effect of variation in managed competition across different communities on expenditure levels would be problematic. Recent Reconfiguration Of Twin Cities Providers Three recent mergers involving Twin Cities HMOs have captured national attention, The first merger involved two large HMOs; the second, an HMO and a hospital; and the third, an HMO and a hospital system. To understand the importance of these mergers, one should view them in the context of consolidation activities that began in the early 1980s and occurred in three phases. The 1980s’ consolidation occurred primarily through formation of multihospital systems, as noted previously. Some on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom MANAGED CARE IN TWIN CITIES 121 absorption of relatively small HMOs by larger ones occurred during this time as well, but it had little effect on the overall HMO market. The beginning of the 1990s saw a substantial shift in the scale of mergers for both hospitals and HMOs. The merger of Health One and Lifespan, two large multihospital systems, raised serious concerns about aggregation of market power relating to the provision of inpatient services. The merger of SHARE and Physician Health Plan (PHP), which created Medica, was the first merger of large HMOs in the Twin Cities and the first HMO merger that resulted in a substantial consolidation of HMO enrollment. As it turned out, these mergers represented only the leading edge of a rapid series of consolidations and organizational reconfigurations in the Twin Cities that have occurred in the past three years. Merger of Group Health and MedCenters. Merger discussions first began between MedCenters and Group Health in 1991 in the wake of the SHARE/ PHP merger. Both organizations were concerned that they would not be able to compete effectively with Medica and Blue Cross/ Blue Shield for employer contracts when employers demanded a “total replacement” product with provider networks that offered comprehensive geographic coverage. What precipitated the merger was the development of the Business Health Care Action Group (BHCAG), a large private employer purchasing coalition in the Twin Cities. The company resulting from the merger, HealthPartners, continued to offer both HMOs as separate products but developed a new joint product (Choice Plus) in response to BHCAG requirements. At the time of the merger HealthPartners had 580,000 enrollees, forty medical clinics (twenty-four owned and eighteen under long-term contracts), four hospital contracts, and approximately $860 million in annual revenues, Together, Medica and HealthPartners accounted for about 90 percent of HMO enrollees in the Twin Cities. Merger of HealthPartners and Ramsey HealthCare. The creation of HealthPartners set the stage for its merger with Ramsey HealthCare. When HealthPartners was awarded the BHCAG contract, it attempted to renegotiate its hospital relationships to be able to deliver services for the premium offered to the BHCAG. HealthPartners issued to all Twin Cities hospitals a request for proposals for new, long-term relationships with the health plan. This stimulated initial discussions between HealthPartners and Ramsey HealthCare in August 1993, which hastened the merger of the two organizations. A formal merger was completed 2 December 1993, with HealthPartners assuming management control of the three different components of Ramsey HealthCare: a hospital with 325 staffed (435 licensed) beds, a 200-member multispecialty physician group (the Ramsey Clinic), and an educational and research unit (the Ramsey Foundation). HealthPartners viewed the merger as an opportunity to achieve better integration on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 122 HEALTH AFFAIRS | Summer 1995 of inpatient and outpatient services, greater cost control, and better geographic coverage for inpatient care in the eastern metropolitan area. Merger of HealthSpan and Medica. The first merger in the Twin Cities between a hospital system and a health plan was announced 8 December 1993: the merger of HealthSpan and Medica. The assets of the existing organizations were merged under a new entity, Allina. At the time of the merger, there were approximately 750,000 members in the existing health plans (550,000 in Medica products and 200,000 in SelectCare, a PPO sponsored by HealthSpan). HealthSpan owned or managed seventeen hospitals in Minnesota and Wisconsin and forty-five clinics and had 3,200 affiliated physicians. Medica was managed by United Health Care Corporation under a long-term management contract and had contracted with 5,000 physicians. Together, as Allina, they became the largest nonprofit firm and the eighth-largest firm in Minnesota. Allina will eventually form the basis for an integrated service network (ISN) that will meet the requirements of an integrated health care delivery system under the new Minnesotacare legislation. Some reduction in the number of hospital beds and consolidation of other services are expected under Allina. Other developments. During the early 1980s, as HMOs gained market share, Blue Cross/ Blue Shield of Minnesota (BCBSM) experienced substantial operating losses. In response, it restructured its health product lines, forming a PPO that by 1990 had more than one million enrollees statewide. It also sponsored a network-model HMO that grew slowly during the early 1980s but had 70,000 enrollees by 1990. Now, with the enactment of MinnesotaCare legislation and recent mergers in the Twin Cities market, BCBSM has begun to pursue the development of ISNs. In June 1993 it announced participation in a partnership with a provider group to form an ISN in the west metropolitan area. In July 1993 it acquired a large, multispecialty physician group practice system, laying the groundwork for an ISN to serve residents throughout the Twin Cities. That ISN will be developed in cooperation with Fairview Health Systems (a multihospital corporation) and the University of Minnesota Hospital and Clinics (UMHC). UMHC is also reassessing its traditional role in the Twin Cities health care market. In 1993 UMHC formed a corporate structure that brought the clinical faculty and hospital together to contract with ISNs and to negotiate with health insurance plans. One result was the BCBSM/ Fairview Health System joint venture. The danger for the university is that providers affiliated with competing organizations could restrict referrals to university physicians and thus restrict their participation in its teaching programs. However, according to the president of the University of Minnesota Health System, “Not to join [an ISN] could mean being left without a patient base in the competitive Minnesota health care environment. At the same time, on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom MANAGED CARE IN TWIN CITIES 123 we won’t be an exclusive partner. Our mission makes it imperative that we be available to any Minnesotan who needs US.” Development Of MinnesotaCare Over the past three years the reconfiguration of the Twin Cities health care delivery system has taken place simultaneously with the implementation of health care reform legislation at the state level. MinnesotaCare was enacted in 1992 through a bipartisan agreement among legislators and the governor. Its general objectives were to enhance the availability of insurance for uninsured persons in the state while reducing increases in health care costs. The legislation created the Minnesota Health Care Commission (MHCC), which was charged with developing a cost containment strategy. The goal was to slow the rate of growth in total private and public health care spending in Minnesota by at least 10 percent per year over five years. Legislation based on the work of the commission established a comprehensive cost containment plan in 1993. This plan encourages the development of ISNs by providers or purchasers of medical care to provide a comprehensive set of health services to a designated population for a prospectively set budget. The state health commissioner was given the power to approve ISN arrangements and issue state exemptions from antitrust liability that might arise. Each ISN will be subject to an overall limit on the rate of growth in its annual expenditures. By 1 July 1997 the intention is that large purchasing pools will be available to all purchasers, regardless of employment status or group membership. Recommendations will be submitted by the MHCC to the 1995 legislative session regarding whether all or some purchasers should be required to obtain coverage through purchasing pools. Recommendations also will be made regarding the creation of a state-administered purchasing pool, which would serve all Minnesotans who do not have access to other purchasing pools, and for permanent market reform strategies based on evaluations of existing reforms and the evolution of national reform initiatives. 28 The immediate impact of MinnesotaCare on the Twin Cities market clearly has been to stimulate collaborative arrangements among providers with the intention of laying the groundwork for ISN formation. Development And Role Of Purchasing Coalitions During the 1980s many analysts familiar with the development of the Twin Cities market expressed disappointment with the actions of employers purchasing care from HMOs. For instance, in 1984 Paul Ellwood said that the “biggest disappointment about health care developments in the on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom 124 HEALTH AFFAIRS | Summer 1995 Twin Cities is the failure of corporations to take advantage of their purchasing power in the market. Major national corporations based here . . . have been unwilling to go out and buy care on the basis of price.” Beginning in the late 1980s some major employers in the Twin Cities took steps to change the way in which they purchased health care. Among these employer initiatives, two efforts-the BHCAG and the managed competition approach used by the State of Minnesota Group Insurance Program (SIP)-have achieved the highest visibility in the Twin Cities. Business Health Care Action Group. In 1988 several large privatesector firms headquartered in Minneapolis/ St. Paul formed a coalition called the BHCAG to lobby for health care reform. In 1991 coalition members decided to create a health plan for their employees and dependents; after a bid process, the MedCenters/ Group Health coalition (HealthPartners) was chosen. At the firm level, the HealthPartners product (Choice Plus) is being offered by BHCAG employers as their basic selfinsured plan. Employees typically can enroll in this plan or select one of the other plans offered by their employer. In most cases, the employer’s contribution to an employee’s health plan is limited to the amount contributed to the BHCAG plan. In 1993, the first year of the HealthPartners contract, 55,000 employees enrolled. Seventy percent of those were previous MedCenters or Group Health members. In 1994, 100,000 employees, 40 percent of all eligible employees, joined the Choice Plus plan. Although Choice Plus is modeled on the HMO concept, HealthPartners is not paid on a capitated basis. Instead, providers are paid on a discounted fee-for-service basis, and each employer has a contract with the participating providers. HealthPartners receives a set fee, currently 8 percent of total expenditures, to administer the program. BHCAG employers estimate that the plan reduced their expected health care costs for enrolled employees by about 10 percent in 1993, as compared with similar coverage available through competing managed care products. An important part of the BHCAG effort is a quality improvement program, consisting of clinical guidelines focused on cost-effective treatment modalities and clinical outcomes assessment programs. Eight HealthPartners medical groups have volunteered to serve as pilot sites to test and implement the sixteen guidelines. Eventually, eighteen medical groups (which provide about 88 percent of the care delivered to BHCAG enrollees) -vill participate in development and implementation of guidelines. The charter organizations that formed the BHCAG believe that knowledgeable purchasing groups are the key to restructuring the health care system. To that end, they believe that the BHCAG has the responsibility to develop quality assurance programs and use its purchasing power to create competing, cost-effective provider systems. While the BHCAG has on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom MANAGED CARE IN TWIN CITIES 125 expressed strong support for competitive health services markets, its actions helped precipitate the merger of two large HMOs-MedCenters and Group Health. However, the BHCAG remains committed to broadening consumers’ choice of health care systems by creating competition among these systems around cost and quality. Its intention is that by 1997 employees will have more health care systems to choose from. State of Minnesota Group Insurance Program. SIP covers 144,000 persons (employees, dependents, and retirees). Until 1985 this program tied its contribution to the premium for the fee-for-service option. In 1985 the program consolidated its HMO offerings and instituted a new contribution formula that required employees to pay the premium difference out of pocket if they did not enroll in the low-cost plan. From 1986 through 1988 the fee-for-service plan continued to have the lowest rate and remained the basis for the employer contribution. Over time, however, the HMOs were able to offer lower rates in addition to their better coverage. In 1989 seven HMOs were low-cost carriers in at least some part of the state. (Plans submit one statewide premium, but not all plans are offered in all counties, so different plans are low-cost carriers in different counties.) Introduction of the low-cost carrier formula led to striking changes in the pattern of health plan premiums. Exhibit 2 shows the trend in the growth of average total premiums for single and family contracts for all state Exhibit 2 Percent Change In Health Insurance Premiums For Minnesota State Employees, 1980-1994 1 9 8 0 -8 1 1981-82 1982-83 1983-84 1984-85 Percent change in average Percent change in average premium for single coverage premium for family coverage 20.26% 14.28% 18.83 18.66 11.29 7.44 13.26 11.50 6.50 8.63 1985-86 0.75 0.89 1986-87 -3.07 -3.39 1987-88 10.28 12.13 1988-89 42.22 41.37 1985-89 12.54 12.75