CINXE.COM

Just a moment...

<!DOCTYPE html><html lang="en-US"><head><title>Just a moment...</title><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><meta http-equiv="X-UA-Compatible" content="IE=Edge"><meta name="robots" content="noindex,nofollow"><meta name="viewport" content="width=device-width,initial-scale=1"><style>*{box-sizing:border-box;margin:0;padding:0}html{line-height:1.15;-webkit-text-size-adjust:100%;color:#313131;font-family:system-ui,-apple-system,BlinkMacSystemFont,Segoe UI,Roboto,Helvetica Neue,Arial,Noto Sans,sans-serif,Apple Color Emoji,Segoe UI Emoji,Segoe UI Symbol,Noto Color Emoji}body{display:flex;flex-direction:column;height:100vh;min-height:100vh}.main-content{margin:8rem auto;max-width:60rem;padding-left:1.5rem}@media (width <= 720px){.main-content{margin-top:4rem}}.h2{font-size:1.5rem;font-weight:500;line-height:2.25rem}@media (width <= 720px){.h2{font-size:1.25rem;line-height:1.5rem}}#challenge-error-text{background-image:url(data:image/svg+xml;base64,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);background-repeat:no-repeat;background-size:contain;padding-left:34px}@media (prefers-color-scheme:dark){body{background-color:#222;color:#d9d9d9}}</style><meta http-equiv="refresh" content="390"></head><body class="no-js"><div class="main-wrapper" role="main"><div class="main-content"><noscript><div class="h2"><span id="challenge-error-text">Enable JavaScript and cookies to continue</span></div></noscript></div></div><script>(function(){window._cf_chl_opt={cvId: '3',cZone: "www.healthaffairs.org",cType: 'managed',cRay: '913a83e3b994fdbb',cH: 'IycUhB_WyaS_Oka4r3ER0cKUmV8A99DBnQ5dN6g0HJI-1739844987-1.2.1.1-iqgIjgAbmYLmOtBOVcgYeRlymF.NGDtP9PkeqP4g_uKIXvJhFP1a.q7tf.0cuHqi',cUPMDTk: "\/doi\/10.1377\/hlthaff.2011.0196?__cf_chl_tk=d6a2GgQICI2WdUk9z8vg8B8t5J.70b.Q.guaLkgZk8Q-1739844987-1.0.1.1-FiDDyqwGvU0.XDKLy3rBl4WZlmxWtya1YuUejC7SoCE",cFPWv: 'g',cITimeS: '1739844987',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/doi\/10.1377\/hlthaff.2011.0196?__cf_chl_f_tk=d6a2GgQICI2WdUk9z8vg8B8t5J.70b.Q.guaLkgZk8Q-1739844987-1.0.1.1-FiDDyqwGvU0.XDKLy3rBl4WZlmxWtya1YuUejC7SoCE",md: "Z866EoHq0Pp3w7vFqWKUN0Bx780zFptZ_DMwPGoLXIY-1739844987-1.2.1.1-zvOGKgEVt1ZldXf5fwcJlAec04CRVCE9QwPDHh6x6fa_HoO4knCaD2WCcfWE.S_Mu4Ktz4k.V7iIKWDIFklCb8voIKLJAH7lSBwj8jG3_35MIFFqxSRB5arWQRMJTMeALi9aUJyku9o3ZFxo79za7RHkJKEBJipgZEzwW1eoYWGTBprpgccHymsj1.dyDHPsmHEAdds.IrxCbsRl4sp9wYj_mLCDLeeJWrti0kxbIxUKhv2ZeM_tevZmQJqNyr6LSHMZRn2MW4wS4hlXDWWLVEQ0Pj4OLI2r4XMLwCa6XFYsRAoJn9p70J.yNdfkt33toyDyRJtzLSb3c9bTrhsSMS2qj119ZdmC.Nn8ItlYw8OdJnIhfI.l5kNMLnPznVWCKpTcB9eVf.gXp6RkXzie.Cy.MsqeuM_DYyQS5FL8bHD7bIuOVkSGwTdVjezww7qKKPamf79T9dBNHtUJIqnP8SBRPoOxvqRiu4rrHBqxiyDeiw.swVec4jpzuEeFp_ZUZlAybF4LyKPvUQZjxjjiNkd4Rv5wJ_ZLyMxAwBqXKNmnZQ4ww5VhJFREZSBz.K2W_U_.sR4Mmut9vGMcaaEg4zI13.kVwyinHZ1Gr5992XYSsZ5Igl3Q0KyvBz_s.ocPcuX65j7adDRHiftSKmBTi_PnLQ8fwDlnxB_ro0slyvj0PmFDtd_Ua1BCwB2ne_vsNAUFVegost1DvrfMy5n3UttKuaCLrAg6B37UAuJkrh.li3Kim7s5MY.FSto46x0gyfkneRjd5yotG0rld6L55ht4mx7jRIwXOa3PQ2KLweNm99r6AFFQZRLuDYfF1z6MXX5rjDDUaOZbyfBuJjh.TP8P0IPCrEm9cVb8F7QbCzq81JP_FVt0WW3S5K0Q1PasaeN7a0M01gsdg1LVnuz6NBiOgEKCcXJiOVx47DtslDqrh6v5Y_O9h22pzqvADfQP_w6OkllVCCW2Odsz9F3emAkIBK.WQQ_qSqxgQb6rxXFy3oPTWysIAyy8bBPoRT7LduWqAW5ZIvnJymMgtGF59hoPD2irU9ODZk8DeTusvlyF5ZzONwd7X2Pe0dyIPCVeafcGDLz.4bhsX.m6vYFaWGtK326N1hSofYJv63WagtC4gnyn0.Np8ItRJYjsZvvA_VYbgsEpHvc2rROTGcu9.X0J4g6hav2QAvdo3mARQqQW7tdAwN2RISYhS7qt0zepVSoP5P0i_pploK4D7rQkY590cS6vc87ZMNYnc6mT2O6iok4OzI1V.dlmhuP2FNJVfXtlzXPVhPZbsvh1Ghj86KJ1M7zX5WpTu_QlNn75I8GI8wZPycKMIH3JU60AAzP6EkM2pLplEhu0CpOg6IGPWezO3ZgUiAIy8NaEf5cbbKOS4ObeSQxiJemBDDpTJXcQH.RIgJPBHx.pQY6ABYHMCQsHmcn4DoMTpohwpfta8gOPBkfC0P2w14fOWEiUfT80BDTkKruoqJIWOlyH.pDyjEeptdUxf1mTyVG3LzZR._aaDQG5oE5CHJuX6.Znq3fMea5.eKN1h4Asyt_B5J5719dl2e3hBeaRQ5UFIOGWTzY5iOIIBEuySWV6VzI9l1flSzYIqbJvpJ99DTxUUVv9xirTOqUOnzdY8TRVJTEyhXFCFVAHrR80ToxAbJrfYkI7NKPtmL5P8IgLVdhSfZo0SvXG8efSP3v5Z3WBNw4r9L6fh.qjonIxvfV90KhFgCb_NU3d_pC9E1jxJ4.QR3Ld71cxwXnR8B1bm8QugzGLnvl4Udf11KGF7ATEDTkkDOOLpKg6F2R0UKSX5tIK8VK_aGDjdxE1eb_eTypzgQkqsvzOrTcJvJSFG7PtGQzZkgbW4MjzBxA4nsluiL1YYR6UQKk4KH3aweyztfz1oqmRokBI.h0G6K66.Xz6HPoWMYwN606OUx6TS_ssCGzwGTQ10nCcsxOSYatiGsUkwGDvCcd2JoaQftvw5GjZL5gNxyBs5CVUGVDpjiXZQSC0qD196XTViYt2.hlvgrnHrnHHscw3BcVXdW.I9Jsr_aGT2qSwMTvOhlqG6Z_3fz2_gl9UCBtFSPqfkjaKo1Vc1t5KJoM4avvNaFJOZhYQdqk4kMk25oBjiU0A9mmW4ofBOBdlVEhzV_RVm_ClRToTDw9XP8kp7.PgifXbVaBSKbmQtdL6RHkc7.PsUcMkVrd014Sm4DRzNiR7aIV1YjAQdr3.ein5lXgnB2G9VcrGOexWNn0H9sF80O7Rlg.A49rG52Tdb6oakCwkWpteoRWf2tAr7MaZ8Rc9PBsiubm5dduywNjYijV4bpedJqHaNrHJwLSfY6RafSimLPaTQHwREW7DIAQo1SNgaI1WiGfAvxUwD9g8qJZzdsR15IRr4YpPi65u24wIUsXx3TVlqpIvWLNGtfZtYGubCFgw56ACa_Jith7DB4FFWFKHrbsXLYdVpnIVl8eB6MT5AkpG6ycaS58hzIIIpjnZ_CPCqrMp97nEVipd6SOQ6yWxqcJfjvO1LQSK2Y14Ly_mnto8IToZ7g.xy7DsfoOfyB3fUuvhOng2PwxIhSNUDwvp__WQhvPI66COEksFG1JE1KNY9D1txTIqsRY",mdrd: "Hzcz4oPv7Jsc3J.NFt1KZqDuCAroVR2a5fwP7LaD3L8-1739844987-1.2.1.1-y6NEjjQzRCUjqSwBvv9aqUP1UNNZfqhusFPdAu2kW.YFpU3D6XdRt61uh8icJ6I13f9ReyqsT.pHRwdnyp49vVc.0Ll2FcB_9DuI8MYeGOAFmkGSGvvAeQcwmzboEc9AKoWOm7iV2uuQ_VPTK_Qj.gWX9JX14Ik3qFyRswESicsKp4OSpp_DqIOHK0MpJ2045xLP8lK_CiTicXgUESAKRbVeVSjWkoWDA9Nw36B6NDg.cd8Ru0y5_RBrn9mD8jVYxfLb3ALhhOFqLaWy.O042ZqVT2vK_n9lunmYejjK6PE0SpHd6xph3oZAN9vZnBv632fi4MXnzGtuqsKJack3QCbFfLEPNZue15eeH.3dZXqToryiNvmCVI3.T7sATBzWrOniCZ297DxBZ5oNxhs3m3a.lFNPxd..fT9QZJD4t_YD_xZr9IMl40hjdHy6Ev4xwr_s.ojpaervmQTpoQwxfKTajj20MjtJymzT2BuIsnf_X41fbgaoA33wpOle5.EKnxeCbbFGusCA3jG1SQMFEZDl0.Sih2MbkF_wypr0p76IBQWoHYo77q5y.ew2g_qm8Wqx1vq0JNEY8xe0Mi6SMZ3WNw2MSeEe3GgMFYwaX7rToKHUOPzMRGTndNSPmnyT2gFQ7BGs0XTeLUe6RdoljXuO3Kr_mofOE_ccyaP4ZIvirCkM61Ld54DDc61q5KBp7cbMRF2lqsFDjowdezMbm9jTPQbFwQminY531CXn9bSDpJ7SRLjqDuDrJ6EEIvijB6kjfGAUX5lbw_O4b6Svt9iI3wj11P1Qx.En8c0AXvlgv61BadgY12WybCqrUvib5GzZIw9_o560P0GfikLKC4tUI_Iy1kgYjqe484hEH8XgGKGDhf.4RBPBYY6M6j7Q9XyeMS_RFXlYabiN2fGHQQ9k5RRy8QYaTWiao2YjvuPr9_ciUGHmPbQcQDBKOV6dhnxcThZKHugK3NodHoGBmpWFyaeRdW9FSCX1Lw_.5_p34DcN83FaJ5ghvFCCvMqdQD10nadPkLvXXmFGb2P2MoOjkTJo46ewjVGn3e9JENgudNyPYPZp9t3buihgs9fa6DL5A0ikyItjRSTWZQobS0G7eU0dMzpAhOiM3HqrfgFKB5nGqz.v393c1epxaAgq2vX_O4aCYt2SndjQW1Keu8xEiMu4NZAPjIhsCSkOJO8buEKcN5V7qN0O.IAApS_RwvW5FalRL_SEWdhRVqxvYQvHTKAqiB8r.w7ZmQJRn4tF5r8.TNKUPiNoRWacrz71dXf4hj63mDTzg8MDoKg4y5usAjUCAyLLRDWk4x1nL4mzBKT4Fc4QH6VIn3v7uGpcMMJcuQMhN4uLwPpS_VEkU_Q0wujKzjcc4A1p2mxOmQtRdvd6A3lN34vQuqR.hfWo1ZpSq0Q5UldDbPeKr0k7FgzaIW_sBm8uZt8xc2Hb1lhBorRgJydYA7BZ5qNiPD9CgOXTI8fqVlMcWUQB6TaprPDg4DjNKtBFq7dhuQbGG53y6kMXzdZW8mjzGpH48mR_Ht7K4rSUhuZB7KXoSaXZ24VQCONAQD5qBKXIKkSA_ATuOjefx6kAPC9lVYkZcO3S17jSXI6xj4TmfkX7eHz3nGVz3pVxcSTAsFuDGqi538h2VMBiOJi_4sVhcA7r9znsxXl.CdhMvL_P.dVpyIJeWM1T_KzCe03vZnSuDo_IFjrHepPCQsYTGmsbHGdhJkfDqR0pxdOzyTdAj.3A85nHQ6.I0OG40L._H05VacPrVLRu8guynlH_i94QHAiJmFSN9NqyoIgLgDmBw0946rq1oqSNl.jhnGwZ51Y8jM2I6VUUxk5GsRXIejgTOX6ELAWfxpJERnh2CuKFADF3J4Z17PM3bXzovjpZcKlGnp6lW.ltSpqQuJGs8VDKFTPpc5GUMpdBBszX7iieJSPeGbGoSZNzjYcy9n75mKrF42On1rYLF_u047a8JC6pZSYXCpJg"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=913a83e3b994fdbb';window._cf_chl_opt.cOgUHash = location.hash === '' && location.href.indexOf('#') !== -1 ? '#' : location.hash;window._cf_chl_opt.cOgUQuery = location.search === '' && location.href.slice(0, location.href.length - window._cf_chl_opt.cOgUHash.length).indexOf('?') !== -1 ? '?' : location.search;if (window.history && window.history.replaceState) {var ogU = location.pathname + window._cf_chl_opt.cOgUQuery + window._cf_chl_opt.cOgUHash;history.replaceState(null, null, "\/doi\/10.1377\/hlthaff.2011.0196?__cf_chl_rt_tk=d6a2GgQICI2WdUk9z8vg8B8t5J.70b.Q.guaLkgZk8Q-1739844987-1.0.1.1-FiDDyqwGvU0.XDKLy3rBl4WZlmxWtya1YuUejC7SoCE" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>