The fundamental substantive change in American healthcare over the past decade has been driven by:

a. Reduction in the total number of financial resources available for the provision of healthcare services.

b. A decreasing number of physicians and nurses creating an increasing level of stress in the capacity to provide services.

c. A fundamental shift from volume to value in both paying and providing for healthcare services in the United States.

d. Insurance companies increasing the price of healthcare insurance coverage and reducing the number of benefits available to users.