Primary care access isn’t guaranteed by health insurance

An excellent article appeared recently in the Washington Post, entitled, “Having health insurance doesn’t ensure it will be easy to find a doctor,” where a young, otherwise healthy and insured woman discusses her extreme difficulty in finding a doctor in Washington, DC who will see her.

“I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of pre-approved doctors and started calling. And I got rejected. Again. And again. (Usually after being put on hold for three or four minutes.) ”

Next to Massachusetts, D.C. has the largest number of physicians per patients. D.C.’s doctor excess is somewhat exaggerated given that there are several teaching hospitals with more than a few resident physicians. However, there are more than enough docs in D.C. to see patients. The problem is that, in addition to not having enough primary care physicians, more primary care physicians are not accepting new patients. The article suggests that this is a supply and demand issue, which is true.

However, another major factor that the article neglects to mention is that there are many primary care physicians in D.C. gladly accepting new patients. However, they will not take your insurance.

I practice in a large, academic teaching center in D.C. and we stopped taking new patients several years ago. This happened because many of the physicians in D.C. stopped taking insurance, and many of their former patients who were not willing to pay out of pocket to see their former doctor came to our practice. The problem is that we now have so many patients, they have a very difficult time getting to see us for an appointment.

The article suggests several solutions to increase the number of primary care physicians, including recruiting more primary care oriented students into medical school and funding more residency spots for graduates going into primary care. These are good ideas but will not solve the problem.

In a survey we did, we found that only 2% of students going into internal medicine were going into primary care internal medicine. The main reason that they chose not to do primary care was lifestyle. Students perceived primary care physicians as too busy, doing too much paperwork, and undervalued by society. Until this problem is fixed, the primary care crisis will remain.

I have previously discussed that the same issue happened with psychiatrists years ago, and this is why we have a two types of psychiatry in the United States. The psychiatry that you see on the TV and in the movies only occurs for those patients willing to pay out of pocket for their care. Those who pay for mental health with insurance might see a psychiatrist once a year for a few minutes, but any counseling is done by someone else. Getting an appointment with a mental health professional that accepts your insurance is similarly challenging.

Though I believe it is important to support health care reform, it will do nothing to fix the lack of primary care physicians nor does it address the root cause of the problem. If you are frustrated by the system, one thing to think about is paying out of pocket to see your primary care physician. Though many doctors who see “cash paying” patients run more of boutique or concierge practice, more and more primary care physicians are seeing patients at more reasonable prices, and just desire to get the insurance middle man out of the picture.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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  • ninguem

    I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of preapproved doctors and started calling.

    United Healthcare is about the worst insurance around. It is almost as bad as Medicaid.

    “……About two weeks later, she produced a list of some 15 practices in the District that she had contacted. Only two were accepting new patients with insurance coverage like mine. But they came with relatively poor online reviews — one doctor was described as “socially awkward” and the other was said to have a brusque staff and exam rooms covered with piles of paperwork…….”

    Not surprising, only the marginal practitioners are desperate enough to work with United Healthcare in the first place. With a lot of practices, like mine, where I will work with the UHC patients I already have from when I was building a practice, but damned if I’ll accept any new ones.

    ……..One friend got a UTI just after she’d moved to Washington and was waiting for her new medical insurance card to arrive. After a week of pain, she saw a doctor at a CVS MinuteClinic in Bethesda. But her symptoms returned two weeks later. “By this point I was desperate,” she wrote to me. “I started calling every doctor listed on my insurance company’s website. I must have made 20 phone calls before I found a doctor that would let me come in. I think I waited about 2 days to see him.” ………..

    For about the same money, the person could have gone to a regular primary care office like mine. Paid cash. So……fine. You want the nurse clinic, stay with the nurse clinic. If they want to play doctor, let them take care of the difficult work as well. I must admit, I get quite sick and tired of cleaning up the messes from the nurse practitoner clinics, and the pharmacies that want to give vaccines. They want to play doctor until the work gets hard.

    What the article author is saying is, not that it’s hard to find a doctor.

    It’s hard to find a doctor who’s willing to be screwed. It’s hard to find a doctor willing to work for free.

    • resident

      Yes, great post
      Accepting medicare, or other low paying insurances, is like working for free in many specialties. We all want to “help people”, but working crazy hours, with low pay, for people who act like they are entitled to as much health care as they can consume, is not what most of us signed up for. Insurance does not equal access

  • Vox Rusticus

    UnitedHealthcare, straight from the leprosarium of insurers, with its bedfellows Aetna and Cigna. What I like so much is not only how they arbitrarily deny perfectly legitimate claims for risible justifications, but how they pimp out their claims to “expediters” who offer to “settle” the claim for 70 cents on the dollar. It makes me pine for my time in the gold and rug souks. At least there, a thief knew he stood to lose a hand if he got caught. Here, they work with the blind eyes of the state insurance commission turned toward them.

    • SmartDoc

      “UnitedHealthcare, straight from the leprosarium of insurers, with its bedfellows Aetna and Cigna.”

      True enough, but the democrats are in the process of intentionally destroying all quality small private insurers coercing folks into these quasi-public politically connected mega-insurers.

      And which carrier has the worst denial of claims? That would be Medicare, soon to get a lot, lot worse.

  • ninguem

    “…….I was able to get an appointment because the doctor I saw, Anna Zamskaya, had just started there……….”

    “……..Zamskaya says she personally doesn’t keep track of the number of patients she has seen, and it’s hard to predict when she’ll have a full patient load. I have a feeling it won’t take long….”

    Sure enough, she found a good doc, taking United Healthcare, because she was a new doc just starting out.

    When she fills up, she will start dumping the bad insurances. And I can’t begin to tell you how bad UHC is. Watch out, she may soon say she’s no longer taking that insurance.

    Now it is possible to see the doctor on a nonparticipating basis. That may turn into an extra ten or twenty bucks a visit. All this desperation to see a doctor might evaporate when it turns out to mean an extra twenty bucks.

  • jsmith

    Well said, ninguem. Part of the problem is that people pay a lot of money for insurance, but they have no idea how little of that money the PCP sees. They’re fixin’ to learn the hard way. Cutting out the middleman is the best answer for some, but a lot of people will resist that, because they think they’ve already paid us well for our labor. They have not. So, it’s to the nurse clinic or urgent care they go….

  • http://glasshospital.com GlassHospital

    Dr. Mintz makes a good point about primary care going the way of psychiatry, which would be sad.

    The Times has an article today about more doctors opting out of private practice models in favor of salaried positions. Less risk, more predictability.

    Like Dr. Mintz, I practice in a large academic medical center because I like to teach and don’t like the hassles of negotiating or billing.

    Private practice strikes me a little like the yeoman farmer envisioned by Jefferson–a nice idea in theory, but soon to be taken over by agribusiness–large conglomerations of providers under systematic care–the Kaisers, Mayos, Cleveland Clinics, and other regionalized health care meccas.

    The fixed costs of running an office, the overhead of staff, billing, and malpractice make being on your own less and less feasible.

    Only the truly brave and adventurous will stay in private practice, more likely than putting the onus of the insurance collection/reimbursement on the patient him or herself. The more that happens, the more the public will cry out for simplified billing and payment systems.

  • H

    Corporate medicine is more efficient. Usually, the Monday after an appointment, my insurance company would pay the claim electronically. Online billing saves paper and postage. Doctors shared medical assistants and nurses, reducing cost. Radiology and lab work is done onsight and ordered with EMR, saving time. Referral through the EMR. All providers have access to all medical records. For urgent care, there is always an appointment available. Ideas are shared between specialties. What’s not to like. The independent ohysician is for the elite.

    • Vox Rusticus

      H:

      Most of those “advantages” you cite are had in any kind of well-managed group practice, not necessarily a corporately-owned clinic.

      Electronic claims submission is common in the smallest of practices. So is shared staff. Billing by email, I wish I could do that more often, but it isn’t for want of lack of facility; most patients still do not accept billing that way.
      EHR is available, not that in small practices it offers much in costs advantages or for that matter, convenience; in large institutional systems, while a much more complicated and expensive enterprise, it potentially offers a ready record at many points at once.

      The success of big multi-physician multi-facility medical institutions is still a mixed bag. Some using the vaunted Mayo model have failed and closed. Larger is not necessarily better and corporate is not necessarily good.

      Want something to eat with your Kool-Aid?

      • H

        You say nothing about the advantages of seeing a doctor in an physician owned practice. In fact, you site the advantage that medical records are available to doctors. One advantage I found the 9 doctors I saw had access to my entire medical record. Several of them helped me with care outside their specialty and reason for visit, providing a new set of eyes on a difficult problem.

        And the cost effectiveness of upgrade to technology for the small group makes more likely they will pass the larger additional cost to consumers. Or perhaps they will shorten appointment times and resent their patients.

  • Vox Rusticus

    H: more Kool-Aid?

    • ninguem

      He has obviously quaffed long and deep of the kool-aid.

    • H

      “H: more Kool-Aid?”

      No Kool Aid: 9 specialists, 5 diagnoses, efficient, convenient.

  • alex

    “What’s not to like.”

    A doctor whose priorities are now 1) pleasing his employer and 2) taking care of the patient? People deride the corruption of business but seem to think it doesn’t have the same effect when replacing physician autonomy. I’ve heard way too many stories of employed doctors getting the “heavy hint” that their referrals need to be to doctors under the same employer (as opposed to whoever does the best job), that they seem to be ordering test X less often than their peers, hint hint, etc. Hospitals and other employers view employed physicians as a revenue stream to be “leveraged”.

  • imdoc

    ” Students perceived primary care physicians as too busy, doing too much paperwork, and undervalued by society…The article suggests several solutions to increase the number of primary care physicians, including recruiting more primary care oriented students into medical school and funding more residency spots for graduates going into primary care.”
    So, it looks like we just need to dupe more people to accepting an unfavorable situation – problem solved.

    • J

      The interesting part is that if you look at this year’s match results, a good percentage of primary care residency spots (in both the allopathic & osteopathic match) went unfilled (not sure about after the scramble). In addition, even though many students may go into medical school interested in primary care, a lot may change their minds.

  • H

    “the corruption of business”

    So now the only appropriate care I can get from the medical system is from a physician owned practice?

    That doctors really don’t have my best interest in mind if they work for a big hospital?

    • alex

      “That doctors really don’t have my best interest in mind if they work for a big hospital?”

      Nobody said they don’t have your best interest in mind. It will just be “in mind” along with the orders given to them by their employer. Doesn’t your boss tell you what to do?

  • joe

    “No Kool Aid: 9 specialists, 5 diagnoses, efficient, convenient.”

    That will be almost two specialists per diagnsosis. In short your primary is little more than a traffic cop directing traffic.

  • H

    “That will be almost two specialists per diagnsosis. In short your primary is little more than a traffic cop directing traffic.”

    Isn’t that their job to help navigate the health care system? Do you think a solo practitioner would have provided a diagnosis without referral?

  • joe

    “Isn’t that their job to help navigate the health care system? Do you think a solo practitioner would have provided a diagnosis without referral”

    Depending on the diagnosis …yes. I know you had a bad experience with a PCP. But honestly, that is an N of 1. If your present primary is doing nothing more than shuttling you to different specialists, then frankly he/she is not doing their job. You don’t need an endocrinologist to diagnose/manage diabetes, a cardiologist to manage stable CHF, a hematologist to diagnose/manage anemia of chronic inflammation. A good PCP can do all of that. The real role of a specialist is for specific abilities (often procedures) the primary does not have and for the confusing/confounding situation. This country has it ass backwards (look at europe).
    PS: I am a medical specialist.

    • H

      “The real role of a specialist is for specific abilities (often procedures) the primary does not have and for the confusing/confounding situation.”

      Yes, it took three years and 6 specialists to diagnose one of my health problems. My experiences with the corporate medical model were efficient, convenient, consultations were done behind the scenes-with my PCP in tow. All labs and radiology were at everyone’s fingertips and because of this, another issue was discovered and confusing/confounding diagnosis was made. My PCP diagnosed one, but sent me off to a specialist for consultation and that problem is now managed in primary care. There is a consensus here that the care I got was substandard because I chose a corporate medical practice…that I must be drinking “kool-aid.” I left the primary care part of this medical center because didn’t like being passed around the office, not because of substandard care or any feeling that any of the doctors just wanted to make a buck from my misfortune. My new provider isn’t efficient or convenient. Radiology is referred out and labs work is sent to an independent lab. Separate bills I have to mail, back and forth between provider and imaging, chart notes I have to make sure get passed around, no appointments on Saturday or late evenings, specialist don’t have access to all my medical records.

      • joe

        Actually H I never have said your care was substandard. I stated: “That will be almost two specialists per diagnosis. In short your primary is little more than a traffic cop directing traffic”
        Which happens to be a true statement. If your present primary is letting 9 specialists manage 4 of your 5 chronic medical problems, then he/she is not really doing much besides directing the traffic. As an experienced subspecialist myself, I must say 9 specialists actively involved in one patient’s care is far far from the rule and frankly a prescription for error unless the primary is actively seeing everything. As an academic doc I see the role for a larged centralized system in certain situations (the zebra diagnosis you had is an example). But the fact is given the time, a good on their own PCP can manage most things. Again your N of 1 is important to you, but in reality it is little more than an anecdote.

        • H

          “If your present primary is letting 9 specialists manage 4 of your 5 chronic medical problems, then he/she is not really doing much besides directing the traffic.”

          I only have one specialist that manages one of my chronic problrems. I see him only because I occasionally have acute problems my former PCP was unable to treat effectively. The others were involved in diagnosis, several of them I only saw once. You’re willing to criticize my primary doctor when you don’t have all the information? Please don’t diagnose me over the internet. I am grateful for the quality of care I received at the evil corporation. I now see an independent nurse practitioner, because as TrenchDoc says, I need a touch-feely provider, not a surrogate PA. I have no criticism for quality of care provided by my former PCP.

          • joe

            H:
            Is it one specialist or nine managing one medical problem or five? Is your former PCP “in tow” of the specialists and a “a surrogate PA” or do you “have no criticism for quality of care provided by my former PCP”. Every reply you make becomes more and more convoluted. Honestly, please point out how I am trying to diagnose anything about you on the internet. My sole point here is to emphasize the importance of the primary care doc in the equation and that specialists from the subspeciality point of view, trying to manage the patient is not necissarily a good thing.

  • ninguem

    Is H a hospital administrator whackin’ his carrot?

    The medical group management association says I should have 4.5 employees. I know of no solo or small group doc that has that many employees. You get over a certain size, you need a level of administration that is not needed in a small group. The MGMA does not gather data on small practices. Any talk about “inefficiency” of small practices is working without data. They look at the large practices and extrapolate to the small practices without actually looking at them.

    Large corporate practices can, indeed, negotiate in ways NOT ALLOWED to small groups, they have the law skewed in their favor. The best example:

    http://www.boston.com/news/health/articles/2008/12/28/a_handshake_that_made_healthcare_history/

    The other side of the Continent, Oregon Health Sciences University had really low malpractice rates. Same with Kaiser in Portland. Maybe it’s their large corporate efficiencies. Or maybe it was because they manipulated Oregon state law to exempt them from malpractice reporting. Or maybe it was because the University limited its total liability to half a million. Not pain and suffering, total liability.

    Same everywhere in between.

    Hey, you find Nirvana in a big corporate practice, fine. I advertise that I’m NOT one of the big corporate entities in my area. One of which, by the way, just got hit with a big fine for using nonprofit dollars and tax dollars to politic for political rules favorable to itself. It’s on the public record. I advertise that I’m not them, that I’m solo. The patients come, just fine.

    “How did you find me?”

    “I was looking for someone in a small practice”

    “Who as your doctor?”

    “I don’t really know, it changed every time I went there.”

    There is no EMR on the planet that replaces the same pair of eyes seeing someone over time. And the corporate setting was so bad, the docs constantly changed. Restrictive covenants kept the docs from just setting up on their own, would have put the corporate entity out of business fast.

  • TrenchDoc

    H
    Under the just passed health care reform your future care will most likely (in the name of cost containment) be handled by a midlevel provider. Not even a PCP because there will not be anymore of those around anyway. Your care of course will be prescribed by the 9 specialists through the EMR and all communication will be by email. I hope you are not one of those needy patients that have to be touched and listened to during your office visits because that is so ineffecient and we will no longer have protocols or any physicians who are trained in hand holding.

  • Trious

    I just moved to DC for Federal Government work and joined Bluecross. I was actually surprised at how easy it was for me to find doctors here as back home in another state, it can be quite difficult

  • JHP.PhD

    Primary care has already gone the way of psychiatry. Most patients are lucky to see their physician one time a year for a few minutes. In most practices that I am familiar with, patients see a PA, be it for healthy or sick visits. If the patient happens to see a physician, it’s usually not “their” physician, but another physician in that practice. The end result is care that is no better than an emergency room visit where the doc reads your chart, treats you, and leaves, and subsequent visits go the same way.

  • http://drackies.blogspot.com Dr. Evil

    I know its crazy, but try paying cash…
    you’d be surprised how fast they’ll see you.

    Frank. M.D.

  • H

    “Is it one specialist or nine managing one medical problem or five?

    One primary managing 4 problems and 1 specialist managing 1 problem. The other 8 were involved in diagnosis and consultation. Isn’t that the way things are supposed to work?

    “No Kool Aid: 9 specialists, 5 diagnoses, efficient, convenient.”

    Where does it say these specialists continue to treat me? That was your assumption.

    “My sole point here is to emphasize the importance of the primary care doc in the equation and that specialists from the subspeciality point of view, trying to manage the patient is not necissarily a good thing.”

    You would be pleased to find that concerns are unwarranted and I received excellent care for a diffucult issue. My point was that the corporate medical model will dominate the medical system because of inherent advantages. I didn’t really ask for your advice on the quality of care by my PCP and how she managed my care.

    • joe

      ” I didn’t really ask for your advice on the quality of care by my PCP and how she managed my care”

      Then do us all a favor who grind away at this job day in and day out, and quit whining about how she didn’t do her job OK? I’ve read your constant gripes on this blog long enough to realize you make little if any sense. Seriously, go back and read what you have written recently as opposed to more and more confrontational replies.
      Goodbye and Goodluck.
      PS: As someone who actually works in a large academic center, I know the large center’s advantages and disadvantages (and it does have some) very well.

      • H

        “Then do us all a favor who grind away at this job day in and day out, and quit whining about how she didn’t do her job OK?”

        Please show me where I say that my PCP didn’t do her job. I was very happy with care she gave me during a difficult period in my life. You’re the one who complained about how my care was managed. I left because of the rotating providers, one of the disadvantages emerging in the corporate model, not because of my PCP.

        I wasn’t the one who introduced the word “Kool aid” to describe the work you do at that fine corporate institution you work for. While the corporate model has some disadvantage, I still feel this is the future of medicine. When small practices go cash only to stay afloat, the quirky and wealthy will have a personal physician, the rest of us will have a medical home. The AAFP has already embraced that model, where chronic conditions are managed by “midlevels.” As midlevels specialize in diabetes management, depression management, etc…can spend the time to educated patients and provide support, with the doctor less involved with ongoing care. A large, multispecialty practice is going to be much more effective at this model.

        It’s the independent providers using school yard taunts to respond to this reality. I have repeatedly praised the care I received. It is your collegues calling the care you provide “Kool aid.”

        • joe

          “Please show me where I say that my PCP didn’t do her job. I was very happy with care she gave me during a difficult period in my life. You’re the one who complained about how my care was managed.”

          I never said any such thing. You did. How would I know? But let’s go back to what you have said about your ex-PCP in your own words over the last few weeks
          “behind the scenes-with my PCP in tow”
          ” I need a touch-feely provider, not a surrogate PA.”
          ” I have 5 chronic diseases and I never had a primary care doctor consider all of these at the same time”
          ” I do not have a typical lifestyle and have never had a primary care doctor consider my priorities when recommending care”
          “It wasn’t the primary care doctor who stepped in when I was spiralling down into despair. When primary symptoms lead to secondary symptoms, it wasn’t primary care doctor that cared.”
          “The one diagnosed by my primary care doctor was erroneously thought to be simple and I ended up consulting a specialist anyway”
          “One of my last visits to my primary doctor before I made the switch to the NP, the doctor’s PA spent 5 minutes with me for a worsening condition that had already been diagnosed. I received no new information from this person, only a new prescription. Level 4-$290. So much for the expertise of a doctor.”
          “. At one time I felt that my primary MD could handle care for this problem and I was horribly wrong so I continue to see this specialist”

          Please, tone down the confrontational attitude Ok? All I am asking here H is a little introspection on your part. Frankly, I don’t agree with my brethran MD’s thinking all corporate medicine/Ivory tower as “Kool-Aid”. It has a role. I have also spent time practicing in rural america where corporate medicine/the ivory tower is nowhere around. That too has a role.
          Think about it.
          Goodnight.

  • ninguem

    “….. the corporate medical model will dominate the medical system because of inherent advantages…..”

    Like Partners rigging the system in Massachusetts and driving up the cost of healthcare? Like the medical center in Portland exempting itself from tort liability the rest of the state has to face? Like the medical center AND Kaiser exempting itself from malpractice reporting laws the rest of the docs in the state face, so they can quietly settle malpractice cases the rest of the state’s docs had to report?

    Yeah, the advantage is they can rig the system to their advantage. Notice I didn’t say to the patient’s advantage. I’m sure sometimes they coincide.

    But what the heck. I’m set up as a professional corporation, so I suppose I’m in the corporate practice of medicine as well.

    Enjoy your kool-aid.

  • TrenchDoc

    There is no doubt in my mind that corporate medicine is where we are going to end up. Much like the rise of Walmaet and the demise of mom and pop stores. Since docs can’t unionize the only way we can get any bargaining power is through corporate medicine. My wife has gotten great care at the Mayo clinic. As a Primary Care Doc and a comsumer of health care I just hate to see my options limited. I want to be able to chose the best medical solution for whatever my problem may be and corporate medicine may not be the right answer in every case.

  • H

    “Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations?”

    Ateev Mehrotra, MD, MPH; Arnold M. Epstein, MD, MA; and Meredith B. Rosenthal, PhD

    Objective: To examine whether integrated medical groups (IMGs) provide higher-quality primary care than individual practice associations (IPAs).

    Conclusions: Patients cared for in IMGs generally received higher-quality primary care than those cared for in IPAs. Having an EMR and implementation of quality improvement strategies did not explain the differences in quality. These findings suggest that physician group type influences health care quality.

    Kool Aid indeed.

  • TrenchDoc

    H
    Does your experience translate to every patient? NO!
    Does my experience translate to every patient? NO!
    Until there is DEFINATIVE proof that one model is superior to another please do not assume your preference is what is universally needed.
    I want as many options as possible for me and my family when it come to health care choices.

  • SmartDoc

    “Primary care access isn’t guaranteed by health insurance”

    Corrected Title: “Primary care access isn’t guaranteed by health insurance that doesn’t contain out of network benefits.”

    There is absolutely no shortage of Primary Care Phyisicians. There is a profound shortage of physicians willing/able to work for free or at a loss.

  • ninguem

    “……Conclusions: Patients cared for in IMGs generally received higher-quality primary care than those cared for in IPAs. Having an EMR and implementation of quality improvement strategies did not explain the differences in quality. These findings suggest that physician group type influences health care quality……”

    Meaning, more little check boxes were ticked in the IMG’s. That’s “quality” in these studies.

    “There is absolutely no shortage of Primary Care Phyisicians. There is a profound shortage of physicians willing/able to work for free or at a loss.”

    Bingo.

    TrenchDoc: “…..My wife has gotten great care at the Mayo clinic…….”

    No doubt. Just make sure you’re not a Medicare recipient at their Arizona campus.

    Must be their great economy of scale H raves about. I see Medicare, but I’m not as smart as those May docs. And despite their integration, they managed to find ways to participate in Medicare in some places, not in others.

    Not that I could do that. Some are more equal then others. You get large enough, you find ways to exempt yourself from rules the rest of us endure.

  • TrenchDoc

    The bottom line here is that reimbursement and risk will determine what patients get seen by PCPs. If the reimbursement is low and or the risk high then the H patients will be referred on to one of 9 specialists. If my reimbursement goes down then I can at least make my work day a little easier by thinning out the difficult patients. It is not right and not fair to patients but it is also not reasonable to decrease my benefits without decreasing my risks and that is exactly what the current health form law does.

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