A stagnant economy and record unemployment have prompted health insurers to alter their plan designs and drug formularies in the Nevada market. HMO market share has eroded by 8 percentage points between 2008 and 2009. A plan for the uninsured launched in Reno two years ago has shown promise in covering the working uninsured; while not insurance, providers and pharmacies offer highly discounted rates in exchange for upfront payment. One of the Reno's provider-owned health insurers, Hometown Health Plan, recently began Health Tracks, an aggressive wellness program in which employer groups must offer a participation incentive or guarantee 80 percent participation. Meanwhile, the financially strapped state is facing significant increases in caseloads for Medicaid, putting even more spotlight on the need to manage medical costs as revenues shrink.