Let's turn our attention to intermediaries. Intermediaries, which we sometimes call other things like plans, payers, insurers and the like, are essential to the functioning of the healthcare system. They provide mechanisms for risk pooling, taking on risk from individuals in the population, which is an essential task in today's healthcare world. And they find themselves right in the middle of many of the most important interactions in health care, handling payments to providers and defining coverage rules that influence the ways that patients can use Care. There are a wide variety of intermediaries out there in the healthcare systems around the world. Many countries operate public intermediaries, insurers or health plans run by or under the auspices of the government, and others incorporate sometimes rely heavily on privately run intermediaries operating essentially as private businesses, and both come in many flavors and combinations. We'll need to spend some time looking at this area from different angles. One good way to get started thinking about intermediaries is to get a handle on their basic goals and the problems they're trying to solve. And a way to get at this is to have a look at the groups they have to work with. Intermediaries face three different groups which they have to work successfully with in order to fulfill their missions. The first is providers. Intermediaries have to work out arrangements with healthcare providers to provide structure for taking care of patients covered by the intermediary and getting paid when they do so. The second is patients needing health care. Intermediaries have to work out the terms under which they'll cover healthcare, which often end up influencing things like what services patients can get, and how easy it is for them to get the services. How they work with these two groups matters. In a basic sense, intermediaries have to get along, at least well enough, with providers and patients, since they have to work together on an ongoing basis. And the ways they work with providers and patients can have a big influence on the way they work with the third group important to them, the people who pay for the coverage from them, their customers or their buyers, if you will. For public intermediaries, this is often the government officials and ultimately the people of their country, who pay the taxes and provide support for their operations. For private intermediaries, this is their customers, the people that are hoping who will buy their products. The ways intermediaries work with providers and patients, will influence the satisfaction people have with their products. If the doctors and hospitals are mad because the intermediary rules or payment levels or whatever are not to their satisfaction, or if the patients are mad, then it's easy to end up with a bad reputation which can make it hard to maintain your political support or hard to sell your products in a marketplace. If everyone's happy, things are easier. The ways intermediaries work with providers and patients also influences the amount of money they have to ask for. For a public intermediary, the amount of money they need to get from the taxpayers, let's say, is closely related to how much they expect to pay out to providers for the care of covered patients. For private intermediaries, the premiums they have to charge are also closely related to the amount they expect to pay for the care of their enrollees. The more expensive the care, the higher your premiums have to be. Now, generally, the more you have to get from taxpayers or the more you have to charge in premiums, the harder it's going to be to be a successful intermediary, maintaining support or selling your insurance products. So what are intermediaries trying to do then? They're trying to figure out ways to work with patients and providers that both maintain those relationships and keep people happy with the care they can get or the care they can provide and the terms under which they can do that. And they also have to keep costs under control. Pay the providers enough, but not too much. Make rules so patients can get the care they want or need, but that's still discouraged over use of low value things. Successfully do this and get the right balance and you survive as an intermediary. You retain the support of your population, or you can successfully sell your products. Blow it in some dimension, and you're in trouble.