Publication
Article
How Health Plans Promote Health IT to Improve Behavioral Health Care
Author(s):
Commercial health plans promote the use of health IT to support behavioral health care access and delivery.
ABSTRACT
Objectives: Given the large numbers of providers and enrollees with which they interact, health plans can encourage the use of health information technology (IT) to advance behavioral health care. The manner and extent to which commercial health plans promote health IT to improve behavioral health care is unknown. This study aims to address that gap.
Study Design: Cross-sectional study.
Methods: Data are from a nationally representative survey of commercial health plans regarding administrative and clinical dimensions of behavioral health services in 2010. Data are weighted to be representative of commercial managed care products in the United States (n = 8427; 88% response rate). Approaches within the domains of provider support, access to care, and assessment and treatment were investigated as examples of how health plans can promote health IT to improve behavioral health care delivery.
Results: Health plans were using health IT approaches in each domain. About a quarter of products offered financial support for electronic health records, but technical assistance was rare. Primary care providers could bill for e-mail contact with patients for behavioral health in about a quarter of products. Few products offered member—provider e-mail, and none offered online appointment scheduling. However, online referral systems and online provider directories were common, and nearly all offered an online self-assessment tool; most offered online counseling and online personalized responses to questions or problems.
Conclusions: In 2010, commercial health plans encouraged the use of health IT strategies for behavioral health care. Health plans have an important role to play for increasing health IT as a tool for behavioral health care.
Am J Manag Care. 2016;22(12):810-815
Take-Away Points
This study examined how a nationally representative sample of commercial health plans encouraged the use of health information technology (IT) to support providers, facilitate access to behavioral health care, and increase opportunities for behavioral health assessment and treatment.
- Health plans have an important role to play for increasing health IT as a tool for behavioral health care.
- A significant minority of health insurance products allowed primary care providers to bill for e-mail communication with patients about behavioral health issues.
- Most products supported online behavioral health referrals, assessment, and treatment.
- Expanding the reach of health IT in behavioral health care could facilitate coordination and integration of behavioral health and general medical care.
Rapid developments in health information technology (IT) are changing the medical and behavioral health care services landscape. With the goals of improving healthcare quality, cost, efficiency, and access,1-6 health IT is the use of electronic information systems that store, retrieve, share, and enable the use of health data to support and streamline healthcare processes. Health IT innovations include a breadth of technologies, from electronic health records (EHRs) and electronic health tools, such as clinical reminders, patient portals, and mobile health applications, to broader tools that enhance patient activation and enable patient-reported outcomes. Although a large-scale investment in health IT adoption and implementation is taking place across the country, behavioral health has largely been left out of the initial wave of infrastructure development.7
Most behavioral health providers were not eligible for federal EHR “Meaningful Use” incentives under the Health Information Technology for Economic and Clinical Health (HITECH) Act.7 Additionally, many remain ineligible for incentives under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which supplements the Meaningful Use program and emphasizes the role of health IT in supporting quality improvement and payment reform.8,9 Although MACRA is Medicare-specific, commercial health plans often take up innovations promulgated through Medicare first. Behavioral health providers generally trail in the adoption, implementation, and use of EHRs.10-13 Moreover, behavioral health providers—particularly specialty addiction treatment organizations—often lack the resources and infrastructure to implement health IT initiatives,11,14-16 resulting in a growing health IT divide between general medical and behavioral health.7,13,17
Expanding the reach of health IT in substance use and mental health treatment is likely to be a key facilitator for coordinating and integrating behavioral health and general medical care.16,18,19 The Affordable Care Act of 2010 encourages investment in integrated healthcare systems, such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), which require continued momentum toward expanding the reach of health IT into behavioral health. A premise of HITECH, and the broader movement toward EHR adoption and implementation, is that EHR systems will facilitate coordination and integration of care.3,16 Accomplishing these goals will likely require incorporating behavioral health into the health IT environment,10 particularly by establishing EHR interoperability and linking clinical data within and between healthcare facilities.16,19 Much remains unclear regarding the overall scope of health IT progress in meeting the goals of improving healthcare quality and decreasing healthcare costs,6,20 and especially, to what extent the investment in health IT will alter or improve how behavioral health care is accessed and delivered, and how it ultimately improves patient outcomes.7,21
As healthcare quality stakeholders, and given the large number of providers and enrollees that they reach, health plans have a key role in encouraging health IT to improve healthcare delivery. Health IT research to date has primarily centered on the role of providers and hospitals; the extent to which health plans influence health IT use to facilitate the delivery of care is still relatively unknown. Two studies found a weak relationship between payer mix and health IT adoption in hospitals, noting no significant associations with commercial insurance.22,23 Few, if any, studies directly examine the relationship of health plans and health IT as it pertains to behavioral health.
In this analysis, we explored how commercial health plans encourage health IT as a way to support providers, facilitate access to behavioral health care, and increase opportunities for behavioral health assessment and treatment. We examined how these strategies vary by how behavioral health care is managed, as having multiple organizations involved may create complexities in implementing health IT approaches. Behavioral health care management may be contracted to an organization outside of the health plan. Some arrangements may promote a specialized focus on behavioral health, while others may promote connections between behavioral health and medical care. Knowing the role that health plans might play in promoting health IT in behavioral health care is critical for moving health IT implementation efforts forward, as health plans often influence the activities of providers in their networks.
METHODSData Source
Data are from the third round of a nationally representative telephone survey of commercial health plans regarding administrative and clinical dimensions of alcohol, drug, and mental health services.24 The survey used a panel design with replacement, as described in previous research.24 The primary sampling units were 60 nationally representative market areas.25 The second stage sampled health plans within market areas.
Senior health plan executives were asked about their top 3 commercial products—based on enrollment—for the 2010 benefit year. The sample included 438 eligible plans, of which: 389 responded to the administrative module (89% response rate), reporting on 939 products; and 385 responded to the clinical module (88%), reporting on 925 products. Results are reported at the product level and weighted based on responses to the clinical module (n = 8427). Health plans were ineligible if they had fewer than 300 individuals (600 covered lives) enrolled, did not offer behavioral health benefits or comprehensive products, or only offered Medicaid/Medicare products. The study was approved by the Institutional Review Board of Brandeis University.
Variables
Health IT variables. Plans were asked about several health IT approaches within the domains of provider support, access to care, and assessment and treatment as examples of how health plans can encourage the use of health IT to improve care delivery. Approaches to support providers included 2 strategies that health plans may use to attract and retain providers in health plan networks (financial support for EHRs and technical assistance for health IT), and whether primary care providers are allowed to bill for e-mail contact with patients specifically regarding behavioral health issues. Approaches to facilitating member access to behavioral health care included offering an online provider directory, online appointment scheduling, online referral system, and provision by the health plan for members to e-mail providers. Approaches to improve behavioral health care delivery addressed both assessment and treatment strategies, and included online self-assessment tools, online personalized responses to questions or problems, and online counseling.
Contracting arrangement. Products were categorized by their approach to managing behavioral health services. Four arrangements were identified: 1) products with specialty external arrangements contracted with a managed behavioral health organization for the delivery and management of behavioral health services; 2) products with hybrid-internal arrangements used a specialty behavioral health organization that is part of the same parent organization as the health plan to manage behavioral health services—these internal behavioral health organizations also have external contracts with other health plans; 3) internal products directly administered behavioral health services; and 4) comprehensive products contracted with a single vendor for both general medical and behavioral health provider networks. Comprehensive contracts, which were reported by only 4 products in 2010, are included in the Table in the total column only.
Statistical Analyses
The findings reported are national estimates. The data are weighted to be representative of plans’ commercial managed care products in the United States. SUDAAN software version 11 (RTI International, Research Triangle Park, North Carolina) was used for estimation of the sampling variance given the complex sampling design. The results reported are based on nonmissing values; missing is less than 5%, unless otherwise noted in the Table. Significant differences by contracting arrangement are based on pairwise t tests with a .05 significance level, adjusted for multiple tests using the Bonferroni correction.
RESULTSProvider Support
To encourage providers to join and remain in their networks, about a quarter of products offered financial support for EHRs, but only 4.5% of products offered technical assistance for health IT needs. These strategies were not specific to behavioral health providers, and may have applied to all providers in the network. Internal and hybrid-internal products were more likely than specialty external to provide financial support for EHRs, while internal and specialty external products were more likely than hybrid-internal products to provide technical assistance for health IT needs.
Many products supported electronic communication between providers and patients, with 27.8% of products that could answer this question allowing primary care providers to bill for e-mail contact with patients specifically for behavioral health problems. However, 34% of products did not know if billing for e-mail contact was allowed. Products with hybrid-internal contracts were more likely to support e-mail contact (38.3%) than products with internal (2.0%) or specialty external (0.8%) contracts.
Access to Care
Products also promoted health IT to facilitate member access to behavioral health services and patient interaction with providers. About 90% of products offered an online provider directory for behavioral health care, and approximately 70% of products offered an online referral system or online personalized responses to questions or problems; few offered member—provider e-mail and none offered online appointment scheduling. Health IT strategies to improve access to care varied significantly by contracting arrangement and product type. Hybrid-internal and internal products were more likely to offer these services than specialty external products.
Fewer than 10% of products facilitated members e-mailing providers for behavioral health problems. This trend was primarily driven by specialty external products, with 66.3% facilitating member—provider e-mails. None of the hybrid-internal products, and only 7.5% of internal products, offered member–provider e-mail for behavioral health problems.
Care Delivery
Overall, a majority of products were engaged in strategies to improve assessment and treatment services using health IT. Nearly all products offered enrollees an online self-assessment tool (94.9%). Fewer offered online personalized responses to questions or problems (70%). Online counseling was offered by 60% of products. Products with hybrid-internal contracts were significantly more likely to offer online personalized responses and online counseling (over 80%) than products with specialty external and internal contracts; fewer than 10% of specialty external and internal products offered online counseling. However, specialty external (19.4%) and internal products (58.7%) offered online personalized responses more frequently than online counseling.
DISCUSSION
This study provides a baseline of health plans’ promotion of health IT strategies at a pivotal point for US health and behavioral health care policy, and fills a gap in the literature around how health IT was utilized in behavioral health care early in the post-HITECH era. Although a limited amount of literature specific to behavioral health and health IT is available, research in general medical settings suggests that health IT has a positive effect on quality, efficiency, and provider satisfaction.26 This research has implications for behavioral health. A 2011 review identified the importance of strong leadership and staff buy-in for successful health IT implementation, and that smaller providers—not only those in large integrated care organizations—can benefit from health IT.26 More leadership for health IT in behavioral health, which has been slower to adopt health IT, could improve behavioral health care quality, efficiency, and coordination between behavioral health and general medical care.
Our findings illustrate that health plans are promoting health IT for behavioral health. However, health plans are limited in how much they can spur adoption of health IT for behavioral health more broadly, because health IT overall still has many limitations (eg, standardization of data, interoperability within healthcare systems, operability outside healthcare environments, lack of or insufficient inclusion of behavioral health data elements) that prevent adequate incorporation and clinical use of behavioral health information.7,20,27 Addressing the limits of health IT to meaningfully incorporate behavioral health information is likely to be a key ingredient in order to successfully integrate medical and behavioral care.7 For example, 2 large payers—Kaiser Permanente of Northern California and the Veteran’s Health Administration—have been leaders in using EHRs to address risky alcohol use in primary care, primarily by using a standardized EHR that includes recommended alcohol screening questions, tracking performance, using clinical alerts/decision support software, and providing positive leadership.28-33 In 2010, commercial health plans were engaging in health IT in all 3 areas that we examined to support providers, facilitate access to care, and improve care delivery. Among provider support strategies, financial strategies were more common than technical assistance strategies. Across the 3 domains, health IT approaches that facilitated access, assessment, and treatment were generally used more often than provider support strategies.
E-mailing providers and online appointment scheduling were infrequent among this survey of health plans. However, both of these approaches are more likely to be activities that provider systems, rather than health plans, operate and encourage; thus, this finding is unsurprising. With increased uptake of patient portals,34 the role of commercial health plans in encouraging access to care and care delivery through portals may grow over time. In the changing healthcare marketplace, health plans are not only payers, but can also play an important role in helping patients to manage their health and healthcare.
Approaches varied by behavioral health contracting arrangement, which points to the influence of health plan organizational characteristics on their health IT strategies. Products with hybrid-internal arrangements were more likely to support health IT for behavioral health than specialty external and internal products. This may result from their unique organizational structure that offers both specialization in behavioral health and a closer relationship between behavioral health and medical care management because of common ownership of the behavioral health organization and the health plan. It may also reflect the challenges that interoperability requires when multiple organizations are involved, as for plans with other behavioral health contracting arrangements.
Compared with a similar study in 2003,35 there has been a large increase in health plans’ health IT strategies in the domains of access and assessment and treatment. In 2003, two-thirds of health plan products offered self-assessment tools, half provided online referrals, one-third provided personalized responses to problems, and only 2% offered online counseling. Most strikingly, in 2010, 60% of products offered online counseling. As health IT moves toward new innovations, like smartphone applications,36 it will be interesting to observe how health plans’ assessment and treatment health IT strategies evolve.
Limitations
Data were self-reported by health plan executives and may not fully reflect what was happening in practice. Provider support strategies had high rates of missing data and were not all specific to behavioral health. Further, it is possible that online appointment scheduling and e-mailing between patients and providers is available to patients at the provider organization level. Additional research is needed to assess what inroads have been made by health plans to promote health IT for behavioral health care since 2010 and in the new MACRA era, including implementation studies to assess which strategies and settings are effective.
CONCLUSIONS
These results suggest important implications for health IT implementation and improvement in the behavioral health sector. Given the current focus on integrating physical and behavioral health care, health IT strategies and EHR interoperability are likely to be important facilitators.37 The success of PCMH and ACO delivery system transformation efforts rests, in large part, on health IT infrastructure development,37 and to what extent behavioral health is included. Moreover, given the low rates of EHR uptake and implementation among providers who were excluded under HITECH12,38,39—which includes many behavioral health providers—it will be important to support behavioral health providers in EHR development and use in the MACRA environment.
Health plans are likely to be key stakeholders in encouraging health IT-oriented activities for behavioral health, and in the shift toward integrated care. Our results indicate that health plans specifically support the use of health IT in integrated care delivery by allowing primary care providers to bill for e-mailing patients about behavioral health issues. As these findings suggest, health plans played an important health IT role in 2010 to facilitate behavioral health care delivery. Health plans may also have a pivotal role moving forward to improve how health IT strategies incorporate behavioral health information and improve the quality of behavioral health care. 
Acknowledgments
The authors wish to acknowledge the contributions of Pat Nemeth, Frank Potter and staff at Mathematica Policy Research, Inc. (survey design, statistical consultation and data collection), Grant Ritter (statistical consultation), and Galina Zolutusky (statistical programming).
Author Affiliations: Heller School for Social Policy and Management, Brandeis University (AEQ, SR, BE, TBC, MTS, DWG, CMH), Waltham, MA.
Source of Funding: This work was funded by the National Institute on Alcohol Abuse and Alcoholism (R01AA010869) and the National Institute on Drug Abuse (R01DA029316). The funding agencies did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (AEQ, SR, BE, TBC, MTS, DWG, CMH); acquisition of data (AEQ, SR, TBC, MTS, DWG, CMH); analysis and interpretation of data (AEQ, SR, BE, TBC, MTS, CMH); drafting of the manuscript (AEQ, SR, BE, TBC, MTS, CMH); critical revision of the manuscript for important intellectual content (AEQ, SR, BE, TBC, MTS, DWG); statistical analysis (TBC, CMH); obtaining funding (SR, CMH); administrative, technical, or logistic support (AEQ, BE); and supervision (SR, CMH).
Address Correspondence to: Amity E. Quinn, PhD, Brandeis University, 415 South St, MS035, Waltham, MA 02453. E-mail: amity@brandeis.edu.
REFERENCES
1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
2. Cresswell KM, Bates DW, Sheikh A. Ten key considerations for the successful implementation and adoption of large-scale health information technology. J Am Med Inform Assoc. 2013;20(e1):e9-e13. doi: 10.1136/amiajnl-2013-001684.
3. Blumenthal D. Wiring the health system—origins and provisions of a new federal program. N Engl J Med. 2011;365(24):2323-2329. doi: 10.1056/NEJMsr1110507.
4. Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5):382-385. doi: 10.1056/NEJMp0912825.
5. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders; Board on Health Care Services; Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: National Academies Press; 2006.
6. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752.
7. Ranallo PA, Kilbourne AM, Whatley AS, Pincus HA. Behavioral health information technology: from chaos to clarity. Health Aff (Millwood). 2016;35(6):1106-1113. doi: 10.1377/hlthaff.2016.0013.
8. Wynne B, Pahner K, Zatorski D. Breaking down the MACRA proposed rule. Health Affairs website. http://healthaffairs.org/blog/2016/04/29/breaking-down-the-macra-proposed-rule/. Published April 29, 2016. Accessed November 1, 2016.
9. Carlson ES. Payment reform and quality reporting under the MACRA [webinar]. American Psychiatric Association website. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Practice-Management/Coding-Reimbursement-Medicare-Medicaid/Payment-Reform/MACRA-Webinar-Slides-June-2016.pdf. Published June 29, 2016. Accessed September 19, 2016.
10. Cohen D. Effect of the exclusion of behavioral health from health information technology (HIT) legislation on the future of integrated health care. J Behav Health Serv Res. 2015;42(4):534-539. doi: 10.1007/s11414-014-9407-x.
11. Williams AB. Issue brief: behavioral health and health IT. The Office of the National Coordinator for Health Information Technology website. https://www.healthit.gov/sites/default/files/bhandhit_issue_brief.pdf. Published September 26, 2013. Accessed November 1, 2016.
12. Wolf L, Harvell J, Jha AK. Hospitals ineligible for federal meaningful-use incentives have dismally low rates of adoption of electronic health records. Health Aff (Millwood). 2012;31(3):505-513. doi: 10.1377/hlthaff.2011.0351.
13. HIT adoption and readiness for meaningful use in community behavioral health: report on the 2012 National Council Survey. National Council for Community Behavioral Healthcare website. https://www.thenationalcouncil.org/wp-content/uploads/2012/10/HIT-Survey-Full-Report.pdf. Published June 2012. Accessed November 1, 2016.
14. Centerstone Research Institute. Behavioral Health/Human Services Information Systems Survey. Software and Technology Vendors’ Association website. http://www.satva.org/documents/InformationSystemsSurveyReportFinal.pdf. Published June 2009. Accessed November 1, 2016.
15. Wisdom JP, Ford JH II, McCarty D. The use of health information technology in publicly funded U. S. substance abuse treatment agencies. Contemp Drug Prob. 2010;37(2):315-339. doi: 10.1177/009145091003700207.
16. Tai B, Wu LT, Clark HW. Electronic health records: essential tools in integrating substance abuse treatment with primary care. Subst Abuse Rehabil. 2012;3:1-8. doi: 10.2147/SAR.S22575.
17. Rosenberg L. HIT: time to end behavioral health discrimination. J Behav Health Serv Res. 2012;39(4):336-338. doi: 10.1007/s11414-012-9297-8.
18. Hu LL, Sparenborg S, Tai B. Privacy protection for patients with substance use problems. Subst Abuse Rehabil. 2011;2:227-233. doi: 10.2147/SAR.S27237.
19. Ghitza UE, Sparenborg S, Tai B. Improving drug abuse treatment delivery through adoption of harmonized electronic health record systems. Subst Abuse Rehabil. 2011;2011(2):125-131.
20. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff (Millwood). 2013;32(1):63-68. doi: 10.1377/hlthaff.2012.0693.
21. Clarke G, Yarborough BJ. Evaluating the promise of health IT to enhance/expand the reach of mental health services. Gen Hosp Psychiatry. 2013;35(4):339-344. doi: 10.1016/j.genhosppsych.2013.03.013.
22. Shin DY, Menachemi N, Diana M, Kazley AS, Ford EW. Payer mix and EHR adoption in hospitals. J Healthc Manag. 2012;57(6):435-448; discussion 449-450.
23. Menachemi N, Hikmet N, Bhattacherjee A, Chukmaitov A, Brooks RG. The effect of payer mix on the adoption of information technologies by hospitals. Health Care Manage Rev. 2007;32(2):102-110.
24. Horgan CM, Stewart MT, Reif, S, et al. Behavioral health services in the changing landscape of private health plans. Psychiatr Serv. 2016;67(6):622-629. doi: 10.1176/appi.ps.201500235.
25. Kemper P, Blumenthal D, Corrigan JM, et al. The design of the community tracking study: a longitudinal study of health system change and its effects on people. Inquiry. 1996;33(2):195- 206.
26. Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). 2011;30(3):464-471. doi: 10.1377/hlthaff.2011.0178.
27. Karakus M, Ghose SS, Goldman HH, Moran G, Hogan MF. “Big Eight” recommendations for improving the effectiveness of the U.S. behavioral health care system [published online August 15, 2016]. Psychiatr Serv. appips201500532.
28. Bradley KA, Johnson ML, Williams EC. Commentary on Nilsen et al. (2011): the importance of asking patients—the potential value of patient report of brief interventions. Addiction. 2011;106(10):1757-1759. doi: 10.1111/j.1360-0443.2011.03587.x.
29. Bradley KA, Lapham GT, Hawkins EJ, et al. Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med. 2011;26(3):299-306. doi: 10.1007/s11606-010-1509-4.
30. Mertens JR, Chi FW, Weisner CM, et al. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial. Addict Sci Clin Prac. 2015;10:26. doi: 10.1186/s13722-015-0047-0.
31. Moyer A, Finney JW. Meeting the challenges for research and practice for brief alcohol intervention. Addiction. 2010;105(6):963-964; discussion 964-965. doi: 10.1111/j.1360-0443.2010.02907.x.
32. Sterling S, Kline-Simon AH, Satre DD, et al. Implementation of screening, brief intervention, and referral to treatment for adolescents in pediatric primary care: a cluster randomized trial. JAMA Pediatr. 2015;169(11):e153145. doi: 10.1001/jamapediatrics.2015.3145.
33. Williams EC, Achtmeyer CE, Young JP, et al. Local implementation of alcohol screening and brief intervention at five Veterans Health Administration primary care clinics: perspectives of clinical and administrative staff. J Subst Abuse Treat. 2016;60:27-35. doi: 10.1016/j.jsat.2015.07.011.
34. Goldzweig CL, Orshansky G, Paige NM, et al. Electronic patient portals: evidence on health outcomes, satisfaction, efficiency, and attitudes: a systematic review. Ann Intern Med. 2013;159(10):677-687. doi: 10.7326/0003-4819-159-10-201311190-00006.
35. Horgan CM, Merrick EL, Reif S, Stewart M. Internet-based behavioral health services in health plans. Psychiatr Serv. 2007;58(3):307.
36. Collins F. How to fulfill the true promise of “mHealth”: mobile devices have the potential to become powerful medical tools. Sci Am. 2012;307(1):16.
37. Bitton A, Flier LA, Jha AK. Health information technology in the era of care delivery reform: to what end? JAMA. 2012;307(24):2593-2594. doi: 10.1001/jama.2012.6663.
38. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians. N Engl J Med. 2008;359(1):50-60. doi: 10.1056/NEJMsa0802005.
39. Adler-Milstein J, Jha AK. Sharing clinical data electronically: a critical challenge for fixing the health care system. JAMA. 2012;307(16):1695-1696. doi: 10.1001/jama.2012.525. 
