There are several key elements required in a health care provider’s contract with a managed care organization (MCO). A typical contract between an MCO and a physician contains definitions, terms, obligations, and other features of payer-provider agreements. Terms and clauses are not expected to be changed, while payment terms that can be renegotiated should be placed in appendices.
For this assignment, you are taking on the role of a provider relations manager at Allianta insurance company. You have an appointment with the practice administrator and physician leader at Ashford Medical Group (AMG), which is a multispecialty practice with 10 health care providers. Currently, AMG is not a participating provider at Allianta. The goal of this appointment is to recruit AMG to be an in-the-network provider at Allianta.
The PowerPoint presentation must include the following:
Identify the justifications for health care providers to contract with Allianta.
Note: Reference Table 3.1 – Payer and Provider Reasons for Contracting in your textbook for information regarding the benefits of being an in-the-network provider.
Discuss the credentialing process.

Examine two important common clauses in the contract: no balance billing and nondiscrimination.

Analyze the importance of provider contracts in maintaining a provider network.

Explain network adequacy and its significance to health plan members.
must use at least three scholarly, peer-reviewed, or credible sources published in the last 5 years
Surprise Bills from Outpatient Providers: a National Survey
J Gen Intern Med 36(3):846–8
DOI: 10.1007/s11606-020-06024-5
© Society of General Internal Medicine 2020
INTRODUCTION
Growing bipartisan support has fueled awareness and proposals to protect patients from “surprise” bills—bills where a
patient unintentionally receives care from an out-of-network
provider. While there is a growing literature on surprise bills
from emergency and out-of-network providers at in-network
hospitals, less is known regarding surprise bills resulting from
visits to office-based clinicians.
An outpatient surprise bill may result from the complexities of provider network participation (e.g., a provider may
be in-network at one location but not another) or inconsistent procedures and communication between patients and
office staff. Outdated provider directory listings can mislead patients to believe an out-of-network provider is innetwork. Yet patients are still responsible for increased outof-network costs. In addition to higher cost-sharing and the
balance bill, patients may have no out-of-network coverage
or have separate (and higher) out-of-network deductibles
and maximums. In a 2018 national internet survey, we
assessed the proportion of privately insured patients that
received outpatient surprise bills, experiences with provider directories, and whether patients obtained reimbursement from their insurer.
allowed for a detailed description of experiences with up to
two out-of-network general medical providers. Experiences
with mental health providers were previously reported and
thus omitted from these analyses.2 A participant was considered to have received a “surprise” bill if they became aware a
provider was out-of-network at the first appointment or when
they received the bill.
RESULTS
Our sample included 1148 privately insured adults ages 18–64
that used outpatient general healthcare in the prior year. Participants were predominately white (69%), female (54%), and
ages 50–64 years (43%) (Table 1). Overall, 3% (N = 207)
received at least one surprise outpatient bill in the last year.
Those with fair or poor self-reported health were significantly
more likely to experience surprise bills. Twelve percent noted
that a provider listed in their insurance directory had either
incorrect contact information or did not take their insurance.
The proportion was significantly higher among those receiving surprise bills (30%).
Of visits to out-of-network providers (N = 654), 39% were
associated with surprise bills. Most out-of-network visits
(70%) were not reimbursed by the insurer, with no out-ofnetwork coverage and an unmet deductible being the most
commonly cited reasons (Table 2). Surprise bills were no more
likely to come from specialists compared with primary care
providers.
METHODS
Survey participants were recruited through KnowledgePanel.1
This internet panel consists of ~ 55,000 households and is
constructed using high-quality probability-based sampling
methods. The survey completion rate was 66%. Weights were
applied to match the sample to the US population and adjust
for panel recruitment, oversampling, and nonresponse. The
NYU School of Medicine and Yale Institutional Review
Boards approved the study and participants were consented.
The survey oversampled those using out-of-network care and
Prior Presentations None
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11606-020-06024-5) contains supplementary
material, which is available to authorized users.
Received June 2, 2020
Accepted June 30, 2020
Published online July 15, 2020
846
DISCUSSION
Among outpatient visits to out-of-network providers, 39%
were associated with surprise bills, representing 3% of
privately insured. Educational level and income were not
associated with receiving a surprise bill, suggesting that
system-level failures rather than patient health literacy are
driving this problem. While patients are reasonably expected to confirm that the provider accepts their insurance
before an office visit, providers—or their office
staff—have a role in discussing network participation before care is delivered.
Similar to previous literature for Medicare Advantage,
Medicaid managed care, and some Marketplace plans,3, 4
directory errors were commonly reported by our privately
insured sample, and 30% of those reporting an outpatient
surprise bill noted an error. Previously proposed federal
JGIM
847
Kyanko and Busch: Surprise Bills from Outpatient Providers
Table 1 Associations of Surprise Bills with Demographic Characteristics and Report of Directory Errors
Total
Demographics
Age
18–34
35–49
50–64
Female
Less than bachelor’s degree education
Race/ethnicity
White, non-Hispanic
Non-white, non-Hispanic
Hispanic
Self-reported health status
Excellent, very good, good
Fair or poor
Enrolled in non-Marketplace plan
Directory errors
Reported directory error†
P
Full sample,
N (weighted %)
Participants with no
surprise bill*, N (weighted %)
Participants with
surprise bill, N (weighted %)
1146 (100)
939 (97)
207 (3)
206 (24)
326 (32)
614 (43)
711 (54)
525 (56)
165 (24)
284 (33)
490 (44)
574 (54)
435 (55)
41 (31)
42 (27)
124 (42)
137 (55)
90 (58)
895 (69)
159 (18)
92 (12)
735 (69)
125 (18)
79 (12)
160 (62)
34 (21)
13 (17)
993 (90)
134 (10)
1019 (93)
826 (91)
96 (9)
833 (93)
167 (79)
38 (21)
186 (92)
0.75
202 (12)
138 (11)
64 (30)
< 0.01 0.28 0.88 0.59 0.45 < 0.01 P values in italics < 0.05 Ns represent unweighted survey participants, percentages were weighted Sample includes English-speaking privately insured individuals in health plans with a provider network using outpatient general health care in past year (N = 1148). Participants using mental health care were omitted from the sample. Participants (N = 2/1148) were omitted if any relevant outcome questions had missing data. Self-reported health status N = 1127; marketplace plan N = 1106; reported directory inaccuracy N = 1140; All other variables: N = 1146 *Participants that used an out-of-network provider were asked, “When did you first know that this provider was not in your insurer’s provider network? You may have been told by the front desk, the provider, or the insurance company.” Participants were considered to have received an outpatient surprise bill if they responded, “At the time of the first visit” or “After the visit (for example, when you received the first bill)” to any out-of-network provider. Participants that did not use an out-of-network provider were assigned to the “No surprise bill” category † Participants that used their provider directory in the last 12 months were asked about a series of directory problems. Those that reported that a provider had wrong contact information or were not in-network were coded as reporting a directory inaccuracy. Participants that did not use their directory were considered to not report an error legislation required that enrollees in private plans have access to accurate directories and are protected from costs related to directory errors.5 Other proposed remedies include increasing provider engagement and accountability for directory information and advancing directory data technology. Limitations of this study include the use of self-report and other possible biases inherent in internet surveys, although non-response bias was mitigated through weighting. The prevalence of outpatient surprise bills may vary by market and plan and our study did not allow us to identify these differences. Table 2 Characteristics of Outpatient Out-of-Network Providers Total When informed provider was out-of-network Before visit At time of visit After visit (e.g. when received bill) Received reimbursement No Reasons for not receiving reimbursement* I had not met my insurance deductible My plan will not pay at all for out-of-network providers My plan does not cover the types of services provided during this visit My insurer rejected my claim I thought it would be a hassle Concerns about confidentiality Other Provider type Primary care provider Specialist Full sample Out-of-network providers with no surprise bill, N (weighted %) Out-of-network providers with surprise bill, N (weighted %) 654 (100) 398 (61) 251 (39) 398 (61) 101 (18) 150 (21) N/A N/A N/A N/A N/A N/A 459 (70) 275 (70) 184 (71) 178 (36) 137 (29) 85 (20) 55 (13) 49 (11) 7 (2) 59 (16) 97 (34) 86 (31) 64 (24) 25 (12) 28 (11) 3 (2) 40 (15) 81 (40) 51 (26) 21 (14) 30 (15) 21 (11) 4 (2) 19 (17) 241 (42) 398 (58) 153 (43) 237 (57) 88 (40) 161 (60) P .73 .58 This table represents 654 outpatient out-of-network providers. 492 participants used an out-of-network provider in the last 12 months; 160 of those saw two or more Ns represent unweighted participants, percentages were weighted When informed provider out-of-network N = 649; received reimbursement N = 647; reasons for not receiving reimbursement N = 457; provider type N = 639 *For reasons participant was not reimbursed for an out-of-network visit, participant could pick more than one reason 848 Kyanko and Busch: Surprise Bills from Outpatient Providers Also, because our data are cross-sectional, we were unable to establish causal effects. Provider networks are an important tool if they give plans leverage when negotiating prices with providers and result in lower premiums.6 Yet, if patients cannot accurately identify in-network providers, networks may unfairly lead to surprise bills and increase patient out-of-pocket costs. REFERENCES 1. 2. 3. 4. Kelly A. Kyanko, MD, MHS Susan H. Busch, PhD 2 1 1 Department of Population Health, NYU School of Medicine, New York, NY, USA 2 Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA Corresponding Author: Kelly A. Kyanko, MD, MHS; Department of Population Health, NYU School of Medicine, New York, NY, USA (e-mail: [email protected]). Funding Information This work is financially supported by the National Institutes of Mental Health (R21MH109783). Compliance with Ethical Standards: The NYU School of Medicine and Yale Institutional Review Boards approved the study and participants were consented. Conflict of Interest: The authors declare that they do not have a conflict of interest. JGIM 5. 6. Ipsos KnowledgePanel Overview. [cited 2020 May 28]; Available from: https://www.ipsos.com/sites/default/files/18-11-53_Overview_v3.pdf. Busch SH, Kyanko KA. Incorrect Provider Directories Associated with Out-Of-Network Mental Health Care And Outpatient Surprise Bills. Health Aff (Millwood). 2020;39(6):975-983. United States Government Accountability Office. Medicare Advantage: Actions needed to enhance CMS oversight of provider network adequacy. GAO-15-710. 2015 August. Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. Online Provider Directory Review Report. [updated 2018; cited 2020 May 28]; Available from: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf. H.R. 5826 — 116th Congress: Consumer Protections Against Surprise Medical Bills Act of 2020, H.R. 5800 — 116th Congress: Ban Surprise Billing Act, and S. 1895 — 116th Congress: Lower Health Care Costs Act. Dafny LS, Hendel I, Marone V, Ody C. Narrow networks on the health insurance marketplaces: prevalence, pricing, and the cost of network breadth. Health Affairs. 2017;36(9):1606-14. Publisher’s Note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reproduced with permission of copyright owner. Further reproduction prohibited without permission. General guidelines for all slides Text is limited to approximately five lines approximately five words per bulleted item Appropriate use of font sizes Insert an image for presentation Slide 1 Introduction Introduction provides sufficient background on the topic and preview major points. In other words, you need to describe what will be covered in your presentation. Be concise and to the point Slide 2 Justifications for Being An Allianta’s Network Provider Reference Table 3.1 – Payer and Provider Reasons for Contracting. Slide 3 Justifications for Being An Allianta’s Network Provider Slide 4 Two Important Common Clauses Slide 5 The Importance of Provider Contracts in Maintaining a Provider Network Slide 5 Network Adequacy and Its Significance Slide 7 Conclusion Your conclusion should be a summary of your presentation and should repeat the main ideas. Do not introduce new ideas in Conclusion. EXPERT REVIEWED Why removing percent-of-charge provisions in managed care contracts won’t address concerns about high hospital charges Implementing fixed-fee provisions would not remove the factors that drive price increases, nor would it reduce administrative hassles or decrease risk. WILLIAM O. CLEVERLEY [email protected] 42 | HFM MAGAZINE | JANUARY 2020 • Advocates of replacing percent-of-charge (POC) contract provisions with fixed-fee payments as a restraint on hospital costs overlook that hospitals wouldn’t be able to reduce their charges except in the unlikely event that fixed-fee payments exceed current POC payments. • Implementing fixed-fee payment could make claims adjudication more difficult for reasons ranging from hospitals’ lack of access to fee schedules to difficulty in validating payment due to ambiguity in contract language. • Fixed-fee payments reduce risk for payers — not providers — because if a provider ends up seeing patients who require a higher level of service, the provider likely will lose money. • Indexed rate limits may be a viable solution for limiting price increases while maintaining financial stability for all parties. H ealthcare figures to be a primary issue in the 2020 elections, with much of the focus on costs — especially hospital costs. A common concern among users of hospital services is the apparent lack of correlation between hospital charges and payment. Although some hospital managed care executives have suggested replacing percent-of-charge (POC) contract provisions with fixed-fee payment as a solution, these proposals are based on three myths regarding the POC payment methodology relative to fixed-fee payment. A closer look at each myth reveals that such a payment change could be problematic for the industry. A better solution is within reach, however: An indexed rate limit in POC EXPERT REVIEWED contracts that would allow hospitals to lower charges without experiencing reductions in payments. MYTH #1: REPLACING POC PROVISIONS WITH FIXED FEES WILL REMOVE THE NEED TO INCREASE PRICES Many managed care executives believe that replacing POC provisions with fee schedules will enable them to lower their current prices or at least restrain price increases. But consider this pricing formula: REQUIRED PRICE = AVERAGE COST + (REQUIRED MARGIN + LOSS ON FIXED-FEE CONTRACTS) POC VOLUME × (1-AVERAGE DISCOUNT %) As the formula shows, the required price that any hospital must set is based on several factors. 1 Actual prices must be set at levels that exceed actual costs. 2 Hospitals, like any business, must generate a profit margin to replace their physical assets and to service debt obligations. 3 Losses on fixed-fee payment plans (stemming from fee schedules that are less than cost) must be shifted to patients who are covered by POC provisions. There would be a gain rather than a loss if actual payment exceeded incurred cost, but that outcome is unlikely given the large losses that usually result from government payment plans. 4 As POC volume shrinks, the resulting price must be increased. Let’s use a case example to help isolate the key factors. Assume we have a POC provision that makes payment for emergency department (ED) claims at 50% of billed charges, and we want to replace that provision with a fee schedule that pays $1,000 for levels 1 and 2 emergency claims, $1,600 for level 3 claims, $4,500 for level 4 claims and $6,000 for level 5 claims. Will this change permit us to reduce our ED charges? The answer is yes, but only if the fixed-fee payments exceed the current POC payment. If the fee schedule payment is less than the POC payment, that loss would have to be shifted to the now smaller base of POC patients, which would result in a higher required price. Negotiating a fixed-fee replacement for a POC payment makes no sense financially unless there is a significant increase in payment. Managed care payers seem unlikely to agree to increase their payment beyond current levels, meaning a reduction in charges would be improbable. Some might argue that removing the POC provision will help reduce patient responsibility amounts. Since collectability on those amounts is not likely to be 100%, this reduction could represent a financial advantage to the hospital. Upon examination, however, this scenario is suspect. Using the ED example, assume current pricing for a level 1 claim is $2,000. At the current 50% payment provision, expected payment would be $1,000. If the claim includes a 20% copayment provision, the patient would pay $200 based on allowed charges of $1,000, and the managed care plan would pay $800. Meanwhile, moving from the POC payment to the $1,000 fixed payment for the level 1 emergency claim would still require a 20% copayment of $200. Even though the initial payment change might be net revenue neutral, the longer-term effect figures to be an increase in the hospital’s prices. To understand this from a mathematical perspective, review the pricing formula again. Given recent trends, government payments can be expected to erode over time. Although some of the loss will be picked up by commercial fixed-fee payments, a sizable portion will not. That shortfall will require an even larger shift to POC plans, resulting in even larger increases HFM MAGAZINE | JANUARY 2020 | 43 EXPERT REVIEWED A closer look at healthcare payment methods To better understand the nature of the three myths, a short description of alternative payment methodologies is critical. The exhibit below presents a scheme for categorizing payment plans by: • Payment basis • Unit of payment Payment basis describes how a payer determines the amount to be paid for a specific healthcare claim. There are three payment bases: • A cost-payment basis simply means that the underlying method for payment will be the provider’s cost, with the rules for determining cost specified in the contract • In a bundled services arrangement, services provided to a patient during a care encounter that are aggregated into one payment unit. For example, health plan contracts often pay for inpatient services on a per-day or per-DRG basis. Payment is fixed based on a negotiated fee schedule (e.g., $1,000 per day to cover all services provided) and is the same regardless of the level of ancillary services provided. Higher degrees of bundling include payment for certain episodes of care or for a covered life in a capitated arrangement. • In a specific services payment arrangement, the individual services provided to a patient during a care encounter are not aggregated. An example is a contract that pays for outpatient surgery based on a fee schedule for the surgery as well as separate payments for any imaging or lab procedures performed. between payer and provider. Costpayment arrangements are rare outside of Medicare payment for critical access hospitals. • A fee-schedule basis means the actual payment will be predetermined and will be unrelated to the provider’s cost or its actual prices. Usually fee schedules are negotiated in advance with the payer or are accepted as a condition Healthcare payment methods In many cases, health plan contracts have elements that appear in more than one category in the exhibit. For example, a contract may call for the hospital to be paid on a DRG basis but stipulate that for all claims in excess of $75,000 in billed charges, the payer will pay the claim at 80% of charges. of participation in programs such as Medicare and Medicaid. • A price-related-payment basis means the provider will be paid based on some relationship to its total charges or price for services. For example, a payer may Payment Basis Unit of payment Specific services negotiate payment at 75% of billed Cost • High-cost • drugs Devices charges for all services or for selected areas such as outpatient procedures. Unit of payment refers to methods of grouping the services provided to a patient: 44 | HFM MAGAZINE | JANUARY 2020 Bundled services • Medicare payment for critical access hospitals Fee schedule • Resource• based relative value scale Ambulatory payment classifications • DRGs • Per diem • Outpatient surgery groups Price related • No contract • Self-pay • Outpatient • Outliers EXPERT REVIEWED in prices. With fixed payment terms in place, and an income target that is essential to preserving the financial viability of the institution, hospitals must either implement draconian cost reductions or increase prices to the smaller block of POC patients. Empirical data indicates an association between lower percentages of POC payment and higher prices. We pulled data from about 300 hospitals in 2018. These were all prospective payment hospitals, with critical access hospitals and specialty hospitals excluded. We determined the percentage of revenue derived from POC contracts and then divided the hospitals into quartiles using that metric. Using 2018 Healthcare Cost Report Information System (HCRIS) data and 2017 Medicare claims data, we then computed the average values for three measures of pricing: mark-up ratios, average charge per Medicare discharge adjusted for case mix, and average charge per Medicare visit adjusted for ambulatory payment classification relative weight. Those values are presented in the exhibit above right. The key finding: hospitals with higher percentages of revenue derived from POC provisions have significantly lower markups and lower prices. The variances are substantial and amount to a 75% to 85% difference between the highest and lowest POC quartile. MYTH #2: FIXED-FEE ARRANGEMENTS WILL BE EASIER TO ADMINISTER THAN POC CONTRACTS Another argument to support the replacement of POC contract provisions with fixed-fee arrangements is ease of adjudication. Some may argue that in POC contracts a payer may deny specific charges. However, payers can and do deny claims or portions of claims that are paid on a fee-schedule basis. Adjudication of claims with fixed-fee terms can be difficult for several reasons. First, anecdotal evidence indicates cases when hospitals lack the fee schedules used by payers to make payment. Either the payers have not updated and distributed new Percent-of-charge (POC) impact on hospital pricing Average markup (charges/ cost) Average charge per Medicare discharge (CMI = 1.0) Average charge per visit (RW = 1.0) Lowest POC payment 5.15 $35,567 $583 Low POC payment 4.39 $32,826 $523 High POC payment 3.78 $30,532 $473 Highest POC payment 2.83 $19,463 $333 Quartile CMI: Case mix index. RW: Ambulatory payment classification relative weight. fee schedules or they do not make downloadable electronic files available to hospitals. In that scenario, the hospitals simply rely on the payer to make the appropriate payment. Second, fixed-fee contracts often contain confusing language that makes validating payment difficult. One issue is a lack of definition for payment terms. For example, the contract may specify fee schedules for orthopedics or cardiology without expressly defining orthopedics or cardiology. A lack of a clearly defined hierarchy in payment is another issue in many fixed-fee contracts. For example, there may be specific case rates for emergency visits and surgery, but the contract may not clearly define whether both are paid if a patient visits the ED and then has surgery, or whether only one is paid and, if so, which takes precedence. To make matters worse, such claims may be adjudicated differently over time as managed care personnel change or a person’s interpretation changes. Payers have more leverage in these matters because they are the ones holding payment. The increased complexity in claims submission and adjudication has spawned an army of revenue cycle staff to deal with the administrative issues, which itself contributes to rising hospital costs. We examined levels of administrative and HFM MAGAZINE | JANUARY 2020 | 45 EXPERT REVIEWED general (AG) expenses reported as a percentage of total operating expenses using HCRIS data from 2011 to 2018. In 2011, AG expenses accounted for 14.7% of total expenses. In 2018, that share had increased to 16.5%. To put this in perspective, the average hospital in 2018 had total expenses of $268 million. If that hospital had maintained its 2011 AG expense percentage, it would have reduced expenses by $4.9 million annually. While the increase in administrative costs cannot be attributed entirely to managed care contract complexity, a portion clearly is associated with the more complex claims administration that results from fixed-fee arrangements. MYTH #3: FIXED-FEE ARRANGEMENTS WILL REDUCE RISK Moving from a POC arrangement to a fixed-fee plan shifts the intensity of service risk from the payer to the provider. If the provider sees more patients who require higher levels of service, the provider stands to lose money. Fixed-fee plans also shift the risk of rising resource prices for items such as drugs to the provider. Moving to payment plans where the bundled unit is even more comprehensive than an encounter, such as with episodes of care or covered lives, shifts even more risk to the hospital. Taking on more risk is viable if the assumption of risk is accompanied with the possibility of greater return, but hospitals’ experiences with larger bundled payment options have been mixed. Some have argued that the risk shift to hospitals will give them greater incentives to become more efficient in care delivery, but the devil is in the details. How can hospitals reduce their costs if they already are relatively efficient, and will additional cost reductions affect care quality? The delivery of specific services for an encounter of care is most likely physician-directed and subject to minimal influence by management. Managed care plans argue that POC provisions provide strong incentives to overprescribe (e.g., do more tests) and to increase prices. Again, management does not order tests or create discharge orders; physicians do. 46 | HFM MAGAZINE | JANUARY 2020 To some extent managed care payers are protected from large rate increases by rate limit clauses in POC contracts. Most often rate increases above a certain level, such as 5%, are neutralized. These provisions shift the risk of increases in resource prices to the hospital. WHY RATE LIMIT CLAUSES ARE A POSSIBLE SOLUTION Rate limit clauses — specifically indexed rate limit provisions — offer a potential solution to spiraling hospital prices. Indexed rate limits exist in a limited number of plans across the country and are easy to understand and administer. Most rate limit clauses are on a “use it or lose it” basis. In an indexed arrangement, however, if the allowed rate of increase is not used, the POC payment percentage increases. As an illustration, assume that a contract pays 50% of billed charges and has a 4% rate increase limit. If the hospital chooses not to increase prices in a given year, the POC payment percentage would increase to 52%. This mechanism would maintain payment at the predetermined rate of increase for both provider and payer. Instead of raising prices or freezing them, assume that the hospital rolls prices back by 20%. The new payment rate would be 65% [(1.04/0.80) X 50%]. A service currently priced at $100 would be reduced to $80 but still be paid $52 ($80 x 0.65), just as if the provider raised the price by 4%, to $104. The key is getting all payers to agree to the inclusion of indexed rate limits. Without acceptance by all payers with negotiated contracts, those choosing not to adopt an indexed arrangement would have lower payments relative to other payers. Fixed-fee provisions may also need adjustment to remove “lesser than” provisions if prices are in fact reduced. About the author William O. Cleverley, PhD, is chairman and founder, Cleverley Associates, Worthington, Ohio. Copyright of hfm (Healthcare Financial Management) is the property of Healthcare Financial Management Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.