As a result, an increasing number of Medicare and Medicaid beneficiaries have been moved into capitated or fixed payment plans to save costs, but this has created a collection problem of the data because under fee-for-service plans Medicare was the largest payer for services provided by home health agencies at 44%; Medicaid came in second with 38%; private insurance and other third-party payers made up 10%; and the remaining 8% came from patients paying directly out of pocket. Capitational plans limit the ability to collect data on home health services because the doctor is charged a fixed fee for the number of patients covered, regardless of how many patients he or she actually provides services to. This makes it difficult to document the specific services provided to the patient, thus making it difficult to justify the need to expand and modify the current program. Another reason home health services data is so difficult to track is that Medicaid programs in fifteen states have implemented self-directed services that allow patients to coordinate their own home health services and compensate family members who provide care. The implementation of self-directed services in these fifteen states has had positive results in reducing the amount of unmet patient need and in enriching health outcomes, quality of life and beneficiary satisfaction at a rate equivalent to that of traditional service directed by the home health agency