Friday, August 11, 2017

MOC and Recertification - As Predicted

David H. Johnson, MD, former board member of the American Board of Internal Medicine (ABIM), authored an opinion piece entitled "Maintenance of Certification and Texas Bill SB1148 - A Threat to Professional Self-Regulation" in the August 7th issue of JAMA. At the end of his article, Dr. Johnson discloses that he served as a member of the American Board of Internal Medicine board of directors from 2007 until 2015 and as board chair from 2013 until 2015.

Dr. Johnson's leadership and influence at the ABIM spanned the time of the purchase of the ABIM Foundation $2.3 million condominium in December 2007, the hiring of the ABIM's felonious "Director of Investigations" (formerly "Director of Test Security") in 2008, the Arora Board Review sting operation in 2009, blind approval of Christine Cassel, MD's conflicts as she simultaneously served on the boards of Kaiser Foundation and Hospitals and Premier, Inc., approval of a $1.2 million golden parachute for Dr. Cassell as she left for the National Quality Forum, and the appointment of Richard Baron, MD who served revolving-door positions from the ABIM, the Center for Medicare and Medicaid Services, the National Quality Forum, and back to the ABIM as he worked to create "seamless" care models for their organization and others.

Dr. Johnson tries to defend MOC by referring to an opinion piece published in 1979 by Arnold S. Relman, MD (who as the editor of the New England Journal of Medicine at the time and a staunch single-payer advocate). But Dr. Johnson failed to mention Dr. Relman's prescient predictions for recertification shortly after introduction of the exercise over 40 years ago:
"Now there are signs that the boards and many of the specialty societies are beginning to have second thoughts about the whole idea of recertification. At the meeting last March of the American Board of Medical Specialties, delegates had such misgivings that they could not agree on whether a specialist's recertification status should even be mentioned in the Directory of Medical Specialists. The Council of Medial Specialty Societies reports that at least four of its constituents societies (representing dermatology, neurological surgery, orthopedic surgery, and radiology) now oppose the idea of recertification, and other societies are said to have 'sizable blocs of members with serious reservations.' At the recent meeting of the AMA's House of Delegates in Chicago, a resolution was taken under consideration that recommends that all specialty boards except Family Practice call a moratorium of recertification. The intent of the resolution is to put an emphasis on mandatory continuing medical education (CME) as a preferred alternative to any kind of recertification program. It is still too early to know whether these developments portend a decisive change in organized medicine's attitude toward recertification, but what seems clear is that the recertification process no longer commands widespread confidence, if it ever did. ... Many doctors are worried that many perfectly competent and conscientious practitioners might be unable to pass recertifying examinations that emphasize arcane facts and the latest literature rather than the practical management of patients. Many doctors also suspect that even voluntary programs would inevitably become compulsory and that the whole recertification process would soon come under government scrutiny and ultimately government control. Reimbursement schedules and hospital staff appointments might then be determined by recertification status; in consequence specialists unable to meet arbitrarily imposed examination standards might find their livelihood in jeopardy."
Dr. Relman's prescient predictions are now most practicing physicians' reality. There is a certain schadenfreude that exists with the physician community toward the ABIM since passage of Texas anti-MOC legislation, SB1148. The ABMS Member boards (and the ABIM in particular) are responsible for Texas Bill SB1148, not practicing physicians. The threat to practicing physicians is not the loss of self-regulation, as Dr. Johnson surmises. Rather, it is loss of trust in the US physician credentialing system that has been spawned by the threats, intimidation and indifference to fraud by members of our bureaucratic physician academic elite within the credentialing community because of the huge profits and control over physicians it generates for their own purposes...

... just as Dr. Relman predicted.

-Wes

22 comments:

Anonymous said...

You just said a mouthful! Wow!

Anonymous said...

Who is protecting the public from this "quality assurance cartel"?
http://www.docinfo.org/#/search/details/687F2095-2E03-4DE2-BC16-DE66308E4A40/

Patient Taxpayer said...

Dr David H. Johnson actually started with the ABIM in 2001 serving on the Oncology Subspecialty Board. He then quickly moved up the ladder being appointed ASCO president 2004-2005 before being quickly elevated to chairman of the ABIM Oncology board in 2007. He served in that capacity until 2011. He also served on the board of directors moving up the ranks to chairman in 2013.

It was not until after being appointed to a leadership role at the ABIM that Johnson took his recertification test in oncology in 2008. Rich Baron and Chris Cassel allegedly took their recertification tests in geriatric medicine also in 2008. I really have my doubts that these folks went to a Pearson Vue center and put themselves out with all the time it takes to study for such a test.

I would like to see actual verification that these three individuals sat for their recertification tests in a Pearson Vue/Prometrics secure testing center (with cameras and identification checks, body searches, and so on) and submitted themselves to the same discomfiting/humiliating conditions as we all are forced into. And that they checked off the pledge of honesty giving away their rights.

I am sorry, but I find it impossible to believe and would like proof.

Could Drs. Johnson, Baron and Cassel post their Pearson Vue email confirmation showing the test date and testing center address that everyone gets when they sign up. Post the confirmation letter at:

https://twitter.com/abimcert

If the good doctors deleted their emails by mistake, their confirmation letters can be retrieved by calling Pearson customer service. They retain email/testing files for at least the past 15 years. I have verified this information already, so I would like to hear it from these three doctors directly that they took their tests at Pearson Vue and signed the pledge of honesty.

Pearson Vue / ABIM Customer Service
American Board of Internal Medicine
Customer Service

Monday–Friday, 7:00 a.m.–7:00 p.m. CT; closed on local holidays.

Telephone

800-601-3549 (toll-free)
+1-952-905-7093 (toll)

Anonymous said...

Well said Wes!

Bobster's 10% Off Club said...

Does ASCO have some major COI regarding MOC?
http://www.instituteforquality.org/qcp/about-qcp

David H. Johnson's ASCO MOC Task Force said...

LOL

The American Society of Clinical Oncology ABIM MOC Task Force features a leadership comprised of, for and by the ABIM. It is of course led by the former chairman of the ABIM David Johnson. The past ASCO presidents' response to MOC has been imo a mock window display for ASCO members. "We will keep you informed."

Can somebody post ASCO's tax filings? That could prove interesting.

Anonymous said...

Look at ASCO's 990 tax filings from the time David Johnson, MD was the president 2004-2005 and then compare their net assets and "current holdings" with the most recent 2015 tax filings. They make for a classic read and confirms that ASCO is more interested in collaborative MOC revenues than doing what is best for physicians and patients.
Schedule R shows many lucrative business partnerships/related corporations. We see municipal bond issuance for real estate investments and multistory complex/holdings. There is a company involved in office space leasing. They have Millennium Funds offshore accounts in the Cayman Islands, Alphakeys International Black Diamond Hedge Funds, massive accounts with publicly traded securities. Flush with cash and other liquid assets. Executive salaries up ten-fold and more.

Anonymous said...

I found the 990 tax forms on Propbublica's nonprofit explorer. ASCO spends hefty amounts on lobbying firms/lobbyists working the legislature and backrooms in DC every year. I won't name the firms, but he amounts they spend are staggering. You have to add it all up where they report it and then look at their contractors list.
I was quite surprised also that it appears ASCO has such a rich financial life they may have to hire two CFOs to manage it all.

ANGUS M said...

Lots of attractive money in MOC as the ABMS carefully calculated and predicted 40 years ago.
From the ACP to the XYZ they all seem to want in on the money at the expense of the practicing physician. And look at the unfortunate deficit of care due to shortages of physicians decades later.

Anonymous said...

I think one particular point bears repeating over and over and over: how does the ABIM and MOC count as self-regulation?

As a "board certified physician," I have no say whatsoever in any of the actions these board decide to take. I have no vote on what fees are charged.

This is a ridiculously simple point to have to make, but how on earth can anyone say this counts as self regulation? Just because doctors sit on these boards doesn't mean they represent the interests of even 0.05% of physicians.

Self-regulation would entail all members having a vote on issues (like a referendum), or having some type of system of electing representatives. That would count as self-regulation.

As much as I dislike the AMA, at least they have mechanisms for voting and representation of some kind.

The ABIM is literally the opposite of self-regulation.

Anonymous said...

Spend some time searching for news on Pearson Vue.

They are doing exactly the same thing to experienced qualified teashers.

http://www.abcactionnews.com/longform/teachers-failing-state-certification-test-at-alarming-rates

What a way to profit - by threatenting peoples' livelihoods with poorly designed and poorly researched tests. Simply evil. If you are a parent (as well as a physician) think about having your kids opt out of all Pearson Vue testing.

This is a many headed hydra!

Anonymous said...

The AMA and ACP are the parent organizations that created the ABIM. The AMA and ACP members who founded the ABIM wrote the original articles of incorporation in 1936. They wrote the bylaws to state that the board and board officers could only consist of ACP and AMA members. And there were strict term limits in place of one to three years depending. Originally there was no independent executive like a Benson, Kimball, Cassel, or Baron to get huge sums of money. It was totally voluntary--all the board positions were unpaid. The ABIM was a fifty year or less "mission" and the ABIM was articulated to be administratively dissolved in 1986 or sooner. What happened just before that to set the stage for all the corruption to come?
Tobacco lobbyist, and ABIM Chairman/ABMS President Thomas Brem, MD rewrote the bylaws to allow an independent executive in 1965 paving the way for the corruption and big money paid to these executives. Brem worked for the special interests groups like big tobacco and with the stroke of his pen ABIM's Chairman Brem opened the door to no-term limits leadership and invited the special interests groups and corrupt politics in. Brem sold out his colleagues and he sold out the American public who suffered the insults and injury. Then came John A Benson, Jr. who became the "father of the new ABIM" selling himself out and his colleagues for a richly paid position. In 1975 Benson made it all "perpetual" with the stroke of his pen and erased the 1986 dissolution date. Brem, Benson, Kimball, Cassel and Baron have all dishonored the ABIM and disgraced themselves. They violated the original pact of lifetime certification and instituted all the corruption of the ABIM and ABMS that we see today.

Wachter and Johnson: Teaming Up To Deliver Solid Financial Results said...

Tobacco Companies ganged up against science and printed propaganda to the public in the 1950' downplaying the link between cigarettes and lung cancer.
https://en.wikipedia.org/wiki/A_Frank_Statement

In 1964 the American Society of Clinical Oncologists was created. Even though the Surgeon General in early 1964 blasted tobacco products and took a bold stance linking cigarettes to cardiovascular disease and lung cancer, ASCO did not mention lung cancer and cigarette smoking in 1964. Why? Did they take out a full page add in the New York Times blasting the lies of the cigarette companies? They did not. Why not?
https://en.wikipedia.org/wiki/American_Society_of_Clinical_Oncology
https://www.asco.org/about-asco/asco-overview/society-history/founders

As late as 1969 ABIM/ABMS head Dr. Thomas Brem testified to Congress giving unscientific evidence that confused and defused the issue of lung cancer and cigarette smoking.

Wes outlines the conflicts of interests over and over again for us at the ABIM and so on.
The ABMS was intended to be comprised of learned clinicians/academicians. Now the ABMS leadership is comprised of business specialists and not medical specialists. They are politicians and not physicians.

Executives, board members, and even the board chairman have been making a market for themselves out of their positions.

We need look no further than the two past back-to-back ABIM Chairman making markets for themselves and the corporations they represent.

Robert Wachter, Chair of USCF Medicine/2015 chair of ABIM is now a board member/governor with the Doctors Company, which offers malpractice insurance to physicians. Wachter was doing videos for TDC since 2016 before being made a governor for the company. Former ASCO president/ABIM Chair, David Johnson, was made ABIM MOC task force leader for ASCO in 2016. In 2016 the Doctors's Company and ASCO announced a partnership to offer a 10% discount on malpractice insurance to those physicians/group practices who were certified by ASCO's new 3-year oncology certification program. Not to forget Robert Wachter was also on the MOC 20/20 Task Force.

And look at all the potential money ASCO has been making on MOC over past several years with 40,000 BC physicians.
http://university.asco.org/moc/earnpoints

COI, Conspiracy And Fraud: Like A Fish In "Wachter" said...

Robert M Wachter and the Doctors Company (Robert M. Wachter was formerly Safety Chairman with IPC the Hopsitalist Company, accused by the DOJ of Medicare Fraud)

2016 Doctors Company Videos featuring Robert M. Wachter
https://www.google.com/search?q=youtube+robert+wachter+the+doctors+company&spell=1&sa=X&ved=0ahUKEwi-lZz1h9XVAhUBJiYKHRtRCqsQvwUIIygA&biw=777&bih=397

2017 Robert M. Wachter appointed governor for The Doctors Company
http://www.thedoctors.com/TDC/PressRoom/PressContent/The-Doctors-Company-Appoints-Robert-M-Wachter-MD-to-Board-of-Governors

David H Johnson, MD and the ASCO MOC Money Factory

ASCO MOC Money
http://university.asco.org/search/site/moc%2520

David H Johnson appointed to lead ABIM/ASCO MOC Task Force to "address concerns"
https://am.asco.org/daily-news/moc-task-force-address-concerns-about-recent-abim-changes

Lucrative MOC Locks Physicians in said...

MOC is not just good for medical specialty societies selling expensive educational products and services, it almost locks you into paying for membership at one of the various specialty societies.

ASCO members get a discount when you buy your MOC/CME study materials at the ASCO Univerisity Bookstore.
Full membership is $600 plus a $35 processing fee.

But there are discounts available also.

"Discounted dues are available to:

Physicians during the first three years after completion of an approved oncology subspecialty training program and who qualify for Full membership. Annual Dues: $300
Physicians eligible for Full membership who reside in a country with a low per-capita income, as defined by the World Bank list of economies. Annual Dues: Low: $50; Lower-Middle: $175; Upper-Middle: $210."

https://www.asco.org/membership/member-benefits/full-members

More verification of non-MOC participation. said...

Out of three oncologists on The Doctors Clinic board of directors sitting alongside Robert M. Wachter, none of these MDs participates in MOC. Robert Wachter, a grandfathered internist, may or may not participate in MOC. We just don't know what to believe after all the deceit we have seen and heard coming from the ABIM.
Even the online publisher Wiley has pulled Dr. Wachter's most popular blogsite from the internet. Was he un-endorsed? Nevertheless, the popular site was sitting idle ever since Wachter wrote his apologia for MOC and the ABIM on June 29, 2015. There was not one truly positive comment to his posting about MOC and the ABIM in reading over all 89 replies.
The blog has been archived by its co-sponsor SHM.

Doctors Company directors bios
http://www.thedoctors.com/KnowledgeCenter/PatientSafety/InformedConsent/Our-Leadership

ABIM verification of non-participation in MOC
http://www.abim.org/verify-physician/Anderson-Richard-d_sUWatnCno=.aspx

http://www.abim.org/verify-physician/Kossman-Charles-LMgYUxpvMxw=.aspx

http://www.abim.org/verify-physician/Rupp-William-EHJqQm8H_UA=.aspx

"And sadly cheating has occurred on a number of occasions!" said...

The anatomy of testing fraud at the ABIM by the MD executives and board of directors

Why Bob Wachter never took his alleged recertification exam at a Pearson Vue testing center (or anyone else who worked for the ABIM)

It is my strong opinion that Bob Wachter never set foot in a Pearson Vue Testing Center. Bob Wachter is replete in actual details about the experience in referencing his own words and writing. In fact Wachter's own spoken words and writing reveal that he does not know what it feels like to be asked for id, photographed, fingerprinted or veins optically scanned; he was never wanded by security and frisked, and forced to turn his pockets inside out. Never told to put his sweater away and be cold. Nor was he was ever ordered to to put his lunchbox, cellphone and rabbit's foot in a small locker. His spouse, or girlfriend, was never told to leave the waiting area without being able to wish him luck. He never sat in front of a camera for 9-10 hours and forced to ask permission to go to the bathroom. He was never put in a panicked state where he must sheepishly ask one of the Pearson test administrators/monitors to explain why his "darn" computer was freezing or going so slowly from page to page that it was lowering his chances of passing. No, he never experienced the strange unsettling sinking feeling of having lab values/ranges that were foreign to his facility's lab values and ranges. And on and on. Not one Wachterian real-world criticism.

If Wachter (or Baron) had tested like the common man and women, this horrid Pearson/ABIM experience alone would have forced him (all of them) to complain about it and express the view that physicians must be treated better than third-class clerks living under an oppressive regime where one has no voice or vote. Wachter's almost flippant remarks about the test and MOC modules proves to me that he was never put in front of any real test. And nobody ever put him to the question of where he took the test, or under oath, if he actually did take it. How could he, or any board member, "study" for the test when you have perhaps been reviewing testing questions and new question pools for years in internal medicine and know the esoteric answers to all the arcane questions. Wachter was at the ABIM for at least seven years prior to taking the exam her refers to with scant careful description.

Read his MOC Controversy. Nowhere does he mention the torture involved in a Pearson Vue testing center experience; nor does Bob reveal the exact (year and date) he took the test. If he actually did take the test at Pearson the heightened state of awareness/anxiety would never let him forget it. I have never heard any shell-shocked physician forget the year they took the test and THE YEAR the next "experience of your life is due".

In June 2015 Wachter wrote that he took the test "about five years ago." That would be 2010. He said the Hospitalist exam was not available (which is not true) so he took the internal medicine recertification exam. As the father of medicine you'd think he'd know that 2010 was the first year that the Hospitalist specialty exam was offered. And you'd think that he would want to lead the charge. But for reasons unknown, Wachter did not take that exam. He speaks of the importance of test pilots to improve EHR and so on. So, what gives here? Why does he misspeak so much.

To prove my point about Bob's ambivalent statements, here it it is according to the ABIM's own website:

"The date for the first ABIM Hospital Medicine examination, a requirement of Focused Practice in Hospital Medicine program, will be October 25, 2010."
http://www.abim.org/news/focused-practice-hospital-medicine-questions-answers.aspx

Anatomy of testing fraud at the ABIM said...

Wachter could not have taken this test and signed up with Pearson. Why does he appear to make fables about his "test experience" for us?. Here is Bob Wachter, the father of Hospital Medicine, in his own words:

"Although I was “a grandfather” myself, when I joined the Board I was required to complete MOC (all Board members must do this, grandfathered or not), and I did so about five years ago. I thought the test (I took the general internal medicine exam; this was before a hospitalist-specific test was available) was reasonable and that studying for it improved my skills. The self-education modules, mostly open-book tests, were also useful, even fun. On the other hand, the parts of the process that required that I measure my own practice were unwieldy, and the tools made available to support this work were relatively user-unfriendly. My colleagues and I on the Board pushed the staff to improve these tools, and over time they did, although they remained well behind the kinds of sophisticated web-based tools we’ve become accustomed to in our non-medical lives."

What all this ABMS-speak indicates is that the board and MD executives do not go to Pearson Vue Testing Centers; instead, if they actually take the exam, they get to test drive their tests with insider knowledge on a fast primed computer at Walnut Street. Did Mr. Mannes the double felon administer the test and fingerprint them? Highly unlikely. He and they were too busy pursuing competing board review courses and sanctioning and suing physicians for "cheating" during this time. They were too involved in influencing Congress. And on and on it goes.

If Wachter took any recertification exam, as required of him by the ABIM, it was pleasant and relaxed. The test was paid for and he and the board got paid by the ABIM for taking the test. Maybe Bob even stayed at Chris Cassel's Dacha and he and Rich went out for drinks afterwards. The whole myth of board and executives "keeping up" is a total facade and sham. This kind of fraud and cover-up at the ABIM/ABMS is decades old. It is an ongoing charade that they must speak about honestly before the secret is totally blown wide open.

Bob continues showing that he does not have the whole experience of the test otherwise "wordy Bob" would have written more about these insults to one's honor/ego. This would have rubbed Dr. Wachter the wrong way and he would never let them get away with the equivalent of a psychological strip search and shining a bright probe light up his "slacks".

Wachter gives no factual experiential data about taking the test. In 2010 Wachter would have most likely had his palm veins optically scanned in his area and not fingerprinted according to my research. Again it is all theoretical experience that Wachter is describing. Not actual real-world sensation and emotion. Or are they all that out of touch with the ordeals people go through? Bob says:

"Critics have also taken on the test itself – everything from the testing procedure (which involves going to secure test centers and being fingerprinted) to the actual substance of the test. They have also looked at the pass rate and pointed to what appears to be an increasing rate of failures.

The secure testing center is necessary given that it is such a high-stakes exam: failure is meaningful, and, sadly, cheating has occurred on a number of occasions. The test itself is written by experts in the specialty, and reviewed in detail by psychometricians to determine that questions are valid and up to date. This is a rigorous, expensive, and time-consuming process."

The MOC Controversy essay written by Bob Wachter
http://thehospitalleader.org/the-abim-controversy-where-the-critics-are-right-where-theyre-wrong-and-why-i-feel-the-need-to-speak-out/

Anonymous said...

Therein lies the problem; it's one of set of rules for the ABMS/ABIM/board elites & another set of (more oppressive) rules for the commoner physician.

When called out on such inconsistencies/unfairness, they circle the wagons and hide behind a laughable facade, saying they know what's good for us. All the while they're spending out hard earned dollars on themselves and their cronies.

The PRACTICING physician knows what best for themselves, and it's not MOC!

Anonymous said...

Dave Johnson is an idiot.

Does he actually think we are rattled if the Federal Government took over MOC or CME? We all WELCOME Federal oversight of the ABIM and ABMS. That way we can punish those who are corrupt and steal money from residents and fellows so they can buy a limo ride and first class airline tickets.

The IRS OIG and the DOJ will be knocking the door of the ABIM on Walnut Street.

20'20 views said...

We agree, there have been a great many idiots at the ABIM on Walnut Street and throughout the ABMS specialty boards. They are idiots because they have typicall allowed themselves to be mouthpieces for special interests.

I see the revolving door executives like cuckoos in an old fashioned city clock that can only say what they have been made to say. They are primed to come out on time and say "cuckoo" for their corporate time-keepers.

But physicians have learned sufficiently by now, or they should have, that they don't have to and should not blindly repeat "cuckoo' in a mindless refrain. They are master propagandists, eerily Orwellian.

All the executives and officers have been puppets, with some pulling the strings behind the scenes, other just dancing to the tune. With their highly paid ministers of propaganda, they have made fools out of everyone. Hundreds of thousands of physicians and the public. And they all got rich and richer growing long noses, because they had no accountability.

State legislation can change all that if some of the loopholes are not too big for them and their profitable partners to slip through. It will be interesting when the civil lawsuits start flooding the courts.

Do they have horns said...

or

Is the ABMS comprised of very clever white-collar criminals?

Should everything the ABIM/ABMS do, say or write come with FTC consumer protection labels?

Based on everything I have read by ABIM authors the answer is yes; and one could easily summarize all their scientific papers with a few basic leit motifs--all highly conflicted and potentially poisonous to the public without proper warnings and words of caution.

All their published material says the following:

"We need more mandates from congress to increase our revenues and solidify our market share. We also need a steady increase in physician fees to support our ever-increasing political activities. This money is important in order to weave our important safety nets for the public. It is urgent to act now ($$$ regardless of any unintended harmful consequences $$$) because of the vital work we are doing to protect the public."

Here is a sample study below at the bottom from ABIM. The title has been modified to reflect current understanding and comes with FTC consumer protection warning labels preceding the link to the article.

Caution: ABIM 2012 'study' conducted by non-practicing physicians making healthcare policy and giving medical advice based on potentially stolen confidential patient information.

Warning: the following study may be in violation of protocols established to safeguard patients' right to decline participation in a study. Danger.

Alert: research document may contain evidence of possible undisclosed experimentation on domestic and international GME programs and patient populations conducted by ABMS, ABIM, and ACGME DINOs.

[Errata: ABIM research title corrected to reflect reality]

"Acceleration is needed in moving to immediately implement ACGME's new pilot GME program based on new and old CBE theories, which we are already experimenting and toying around with at undisclosed GME programs overseas.
These changes will improve our bottom line and prove to our international partners that we are legitimately following the same course here in the US that we invented on the spot for them. Such acceleration will enhance the regulatory capture built into previous healthcare legislation without anyone being the wiser.

(Hint concerning experimentation on human populations in Asia and the Middle East: See ABMS-I + Singapore + Middle East + ABIM + ABMS + ACGME + Eric Holmboe and.)

Is it folly or fraud that moves these people? Or is it just for the fat paycheck? It appears to be all three?

Here is the original title and link to the ABIM article with only one more product warning alert.

Skull and crossbones! Call a real physician immediately if you swallow any of the following conflicted ABIM content by mistake. Beware of words such as "chasm", "gaps", "fissures" or any other such "divides" that physicians or the public can fall into.

"Gaps In Quality Of Diabetes Care In Internal Medicine Residency Clinics Suggest The Need For Better Ambulatory Care Training
Lorna Lynn, Brian J. Hess, Weifeng Weng, Rebecca S. Lipner and Eric S. Holmboe"
http://content.healthaffairs.org/content/31/1/150.abstract