evidence-based medicine is being used to determine when lower-cost medicine may in fact be more effective. Critics of managed care argue that "for-profit" managed care has been an unsuccessful health policy, as it has contributed to higher health care costs (25–33% higher overhead at some of the largest HMOs), increased the number of uninsured citizens, driven away health care providers, and applied downward pressure on quality (worse scores on 14 of 14 quality indicators reported to the National Committee for Quality Assurance). The most common managed care financial arrangement, capitation, places healthcare providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Small insurers, like individual consumers, tend to have annual costs that fluctuate far more than larger insurers. The term "Professional Caregiver Insurance Risk" explains the inefficiencies in health care finance that result when insurance risks are inefficiently transferred to health care providers who are expected to cover such costs in return for their capitation payments. As Cox (2006) demonstrates, providers cannot be adequately compensated for their insurance risks without forcing managed care organizations to become price uncompetitive vis-a-vis risk retaining insurers. Cox (2010) shows that smaller insurers have lower probabilities of modest profits than large insurers, higher probabilities of high losses than large insurers, provide lower benefits to policyholders, and have far higher surplus requirements. All these effects work against the viability of healthcare provider insurance risk assumption. Performance measurements As managed care became popular, health care quality became an important aspect. The HMO Act in 1973 included a voluntary program of "federal qualification", which became popular, but over time this role was largely taken over by the National Committee for Quality Assurance (NCQA), which began accrediting plans in 1991. Accreditation by the NCQA is often expected or require by employers. The Healthcare Effectiveness Data and Information Set (HEDIS) is a prominent set of measurements and reporting on it is often mandated by states as well as Medicare; as of 2017, HEDIS data was collected for plans covering 81% of the insured. Performance measurements can be burdensome on doctors; as of 2017, there were an estimated 900 performance measurements, of which 81 were covered by HEDIS, and providers used a combination of electronic health records and manual data entry to collect and report on the data. Aside from the NCQA, other organizations involved in quality include the