Category Archives: CMS

Models, Models, Have We Got Models!

FierceHealthcare.com today reported that CMS (those lovely folks with all them rules), launched three new policies Tuesday that continue the push toward value-based care, rewarding hospitals that work with physicians and other providers to avoid complications, prevent readmissions and speed recovery.

The newly finalized policies are meant to improve cardiac and orthopedic care, and also create an accountable care organization (ACO) track for small practices, according to the report.

There will be three new cardiac care payment models for hospitals and clinicians who treat patients  for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.

Federal officials said that the cost of their care…varied by 50% across hospitals and the share of patients readmitted to the hospital within 30 days also varied by 50%. Medicare, the article points out, spent more than $6 billion in 2014 for care provided to 200,000 Medicare patients who were hospitalized for heart attack treatment or underwent bypass surgery.

As for orthopedic care, the new payment model is for physicians and hospitals that provide care to patients who receive surgery after a hip fracture, other than hip replacement.

They also finalized updates to the Comprehensive Care for Joint Replacement Model, which began earlier this year.

So far, that’s three models. But wait, there are more where those came from.

There’s the new Medicare ACO Track 1+ Model, that has a more limited downside risk than other tracks in the Medicare Shared Savings Program (another model I discussed a while back in the post, “Shared Savings ACO Program reaps the most for Primary-care Physicians“).

These new five-year models provide clinicians with other ways to qualify for a 5% incentive payment through the Advanced Alternative Payment Model (APM) path under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program. (three more models — so many, in fact, I am losing count)

Why am I pointing out the problem with the release of new payment models?

I’ll tell you why. When I began my MHA (Masters in Health Administration) degree program, I took an online elective on Healthcare Quality. The textbook we read discussed how CMS over a period of several decades, created and instituted so many models and programs, that it made me wonder why our health care system was so complex, expensive and so out of whack compared to health care systems of other industrialized countries.

The answer was simple. Too many models, programs, rules, and so on that only gum up the works and make real reform not only impossible, but even more remote a possibility as more of these inane models are added to what is already a broken system.

Winston Churchill said that you can always count on Americans to do the right thing, after all the other things were tried. We are still on the trying part, and I am afraid we will never get to where Sir Winston said we would.

 

Tug-of-War Over Ailing American Knees: What the Medical Tourism Industry Should Know

Total knee replacements in the US is growing, according to an article today in Kaiser Health News.

660,000 are performed each year, and will likely grow to two million annually by 2030, as reported by Christina Jewett. Knee surgeries are one of surgery’s biggest potential growth markets, and one that the medical tourism industry needs to be aware of.

Ms. Jewett described how an orthopedic surgeon from the Bronx, underwent his own knee surgery in a Seattle-area surgery center performed by a friend of his. The surgery began at 8 am, and by lunch, the doctor was resting in his friend’s home with no pain and a new knee.

Medicare is contemplating whether it will help pay for knee surgeries outside of hospitals, either in free-standing centers or outpatient facilities. Several billions of dollars are spent every year by Medicare for knee replacements, so what may be a bold experiment, may soon be more standard.

However, this issue is dividing the medical world, and the issue of money is just as important as the issue of medicine, according to Ms. Jewett.

Some physicians are concerned that moving surgeries out of hospitals will land vulnerable patients in the emergency room, but proponents say it will give patients more choice and better care. In addition, they contend that it will save Medicare hundreds of millions of dollars.

An “overwhelming majority” of commenters, Ms. Jewett states, said they want to allow the surgeries out of hospitals, as specified in recent rule-making documents.

Even if a policy change is made, according to the article, Medicare would still pay for patients to get traditional inpatient surgery. There would be a huge shift in money, the article reports, out of hospitals and into surgery centers.

Medicare could save hundreds of millions of dollars if it no longer paid for multiple-day stays in a hospital, and investors at outpatient centers could profit greatly, as well as some surgeons, especially those who have an ownership stake in the facility.

An open question remains as to whether this shift is beneficial for patients. Patients on Medicare tend to spend nearly three days in a hospital, and forty percent also spend time in a rehabilitation facility for further recovery.

Data from 2014 suggests that Medicare patients are taking advantage of the post-operation support at hospitals and aftercare centers. However, it is unclear what the percentage of eligible patients would choose outpatient care.

Of equal concern to patients are the financial consequences, and here is where the medical tourism needs to pay attention, because even though less care is given, outpatient procedures require higher out-of-pocket costs.

Medicare covers inpatient procedures 100%, with no co-payment, but outpatient procedures require a 20% co-payment, which could easily add up to thousands of dollars for knee surgeries.

One surgery center in California advertises a knee replacement surgery for $17,0300, and those who support the change in policy believe that a strict criteria should be used by doctors to choose which patients are good candidates for outpatient surgery.

All this began in 2012, Ms. Jewett states, when Medicare first considered removing the surgeries from its “inpatient only: list. At that time, many doctors and hospitals protested, calling the proposal “ludicrous” and “dangerous”, and Medicare abandoned the idea.

Another objection cited research that showed that patients who received such surgeries as outpatients were twice as likely to die, and that even one-day stays were twice as likely to need follow-up surgery.

A panel recommended that Medicare remove the procedure from the “inpatient only” list in August, but if they make a change, it will not go into effect for a year or so later.

It is quite obvious to this writer what you in the medical travel industry need to do, but then again, when did you ever listen to what I say?

I’m Back

To quote Michael Corleone, in the Godfather, Part III, “just when I thought I was out…they pull me back in.” To blogging again, that is; not joining the Mob.

There is so much to catch up on in my absence, that I decided to apprise you, my loyal readers, of a subject I discussed earlier this year, the proposed Amendment 69 in the state of Colorado.

To refresh your memories, Amendment 69 (couldn’t they come up with another number?), also called “ColoradoCare”, was an attempt to create a single-payer system in the Rockies.

My previous three posts, “Colorado Gets Real on Workers’ Comp and Health Care”, “Colorado “Single Payer” in Health Care Industry’s Sights”, and “A Little Disruption is a Good Thing” outlined the plan for single-payer, the opposition to single-payer from the health care industry, and how it would be a good thing to have some disruption, especially in workers’ comp.

My writing on the subject also got the notice of a fellow writer, Katie Kuehner-Hebert, of Workers Comp Forum, a sister publication of Risk & Insurance magazine. Her article discussed whether the proposed amendment would be helpful or harmful for workers’ comp payers.

Last month, the voters in Colorado defeated the measure by a wide margin. On election night, at 8:30 p.m., with nearly 1.8 million votes counted across the state, the amendment was trailing 79.6% to 20.4%. Vote totals at 7 a.m., the next morning, with 86 percent of the vote counted, the measure continued trailing at roughly the same percentage or 1,833,879 to 467,424.

As reported in the Denver Post by John Ingold, throughout the campaign, the measure had polled better with Democrats than Republicans, and even in left-leaning Denver, the amendment lost by 2-to-1.

What does the defeat of the single-payer measure mean for the future of health care and possibly workers’ comp?

It means that until there is a nation-wide push for single-payer, state-specific measures such as Amendment 69 will either go down to defeat, or be scraped altogether, as happened in Bernie Sanders’ home state of Vermont. Amendment 69 was an attempt to get there, but as I followed up some weeks later, it was targeted by the health care industry, and never had a chance.

That brings me to my next topic. The recent political campaign that witnessed a misogynistic, egomaniacal, sexist, racist, Corporatist/Fascist bully and demagogue elected president, and a Congress of like-minded semi-demagogues.

Now this capitalist clown is appointing men to his cabinet who stand in opposition to many things the American people believe in, and one man, Representative Tom Price, R-GA , an ardent opponent of the ACA, is to be Secretary of the Department of Health and Human Services, the department which oversees the Centers for Medicare and Medicaid Services (CMS), who makes the rules for the health care law and the other medical insurance programs of the government.

Folks, that’s like putting the fox in charge of the hen house. Sooner or later, the chickens are going to be devoured, except it won’t be dead chickens lying around, but millions of Americans who will lose their health care newly won, and who may die because of it.

We still don’t know what will happen to the ACA after January 20th, because that man refuses to release his tax returns, refuses to commit to anything and goes off on tirades on Twitter to anyone who gets in his way. But I believe that this idiot and Congress will take away not only health care for millions, but eliminate Medicare and Medicaid, which is what Speaker Paul Ryan wants to do, but may be forced to back down once opposition gets wind of it.

Either way, health care in this country will get worse, not better.

That moron soon to occupy the White House has even nominated the CEO of a fast food chain to be Secretary of Labor. This guy, Andy Pudzer (or is it Putzer?, or just plain Putz?) wants to replace fast food workers with robots. Methinks he is one.

True, by 2025, it is predicted that 50% of all occupations will be replaced by automation, but the reason Pudzer wants to replace fast food workers with robots is so that the companies won’t have to pay living wages of $15 an hour to their workers.

I guess this putz would like to see workers thrown out into the street, especially younger minority workers who generally take these jobs to give themselves some work experience, and older workers left out of the changing economy.

You know what 50% less workers mean for workers’ comp? 50% less claims adjusters, physical therapists, durable medical equipment companies, pharmacy benefit management personnel, etc.

It also means that there will be more unease, anger, and maybe even violence. The kind of violence that has been avoided for decades, and that was predicted more than one hundred and fifty years ago by a certain German writer. And what if that 50% goes to 75%? What then?

One idea is to give these permanently unemployed a universal basic income (UBI), but with this Congress, that too will not happen.

There is an old Chinese curse that is appropriate now: “May you live in interesting times.” Interesting, possibly; dangerous, most definitely.

A Simple Friday Morning Health Care Philippic – (With Apologies to Simon & Garfunkle)

Health Affairs blog today posted an article about the new rules CMS released on Wednesday that would establish key parameters for the new Quality Payment Program, a framework that includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These policies were established by the latest, permanent ‘doc fix,’ the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

My writing this morning is not about the proposed rule, the Quality Payment Program, the Merit-based Incentive Payment System (MIPS), or the Alternative Payment Models (APM’s).

But rather, it is about something I first encountered during my first MHA class on Health Care Quality. Reading the assigned readings in the one textbook we were given, I noticed that throughout the last several decades, CMS has released and created many rules, programs, models, and whatnot, that made my head spin. No doubt that is what the good folks at CMS intended, because these rules, programs, models, schemes and “solutions” have only seemed to make the American health care system more complex, confusing, bureaucratic, wasteful, idiotic, and expensive.

When supporters of the current challenger in the Democratic Party presidential primaries say that their candidate will give them free health care, do they really understand and realize how much of a house of cards the entire system is, and one that will collapse if given enough time?

How so, you ask? Well, if you know of any other human-devised system that is so top-heavy, so convoluted, and so complex that the sheer weight of its rules, regulations, laws, programs and models will cause it to collapse, let me know, because the US health care system is the only one I see.

What those who advocate Medicare for All don’t realize (I am one too, but I realize what is at stake), is that even with all of this complexity, people are profiting from the ever continuing releasing of proposed rules, programs and models, and that to simply do away with them is equally as bad as letting it collapse, but at least when it does collapse, we can start all over again and provide the single payer system they want.

Yet, if we scrape it now, those who just got health coverage will lose it, those who never had it will never be able to afford it, and the entities that profit from it will work day and night to prevent the scraping of their “golden goose”.

I don’t have all the answers, but I know this, too many rules, programs, incentives, models, schemes, etc, etc, and so forth, only makes things worse, not better. I don’t remember learning about other nations’ health care systems being so top-heavy and so complex, and maybe, in the final analysis, is why their systems work, and ours does not.

When an American citizen goes abroad and needs medical care in a country such as France (I read one person’s account of what they experienced), the bill they received after treatment was only a few dollars, not hundreds or thousands. Why is that? Maybe because they don’t have a CMS screwing it up.

Maybe it’s because their doctors don’t wave expensive watches in the faces of their patients, or describe their recent safaris where they shot some endangered species in Africa because they were wealthy and believe they have the right to do so, as a Midwestern dentist did last year to a prized lion.

I also remember that during the run-up to the enactment of the ACA, many senior citizens demanded that the government keep its hands off of their Medicaid, and that they did not want some government bureaucrat to make health care decisions for them and their families. Who do they think makes these decisions in health insurance companies? Do they know any corporate “bureaucrats”, or do they think that because they work for a private company, that they are not part of a bureaucracy?

I’ll end this philippic here, but it makes me wonder why we haven’t gotten wise to the fact that too many cooks, too many rules, etc., only make things worse, not better. We need to wake up and join the rest of the industrialized world.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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Final Rule for Bundled Hip and Knee Replacements Published

Four months ago today, I wrote a piece called, “CMS to Require Bundling of Reimbursements for Hip and Knee Surgery”, that said the Centers for Medicare & Medicaid Services (CMS) will require the bundling of reimbursements for hip and knee surgeries.

Today, Health Affairs blog published an article reporting that CMS has recently published the final rule for the Comprehensive Care for Joint Replacement (CJR) model, which is a mandatory bundled payment model for lower extremity joint replacement (LEJR) services in certain geographic areas.

The article, by Patrick H. Conway, Rahul Rajkuma, Amy Bassano, Matthew Press, Claire Schreiber and Gabriel Scott, said that hip and knee replacements are the most common inpatient surgery procedures for Medicare beneficiaries, and can require long recovery and rehab periods.

The authors said that in 2014, more than 400,000 beneficiaries received hip or knee replacement, which cost more than $7 billion just for hospitalization.

They also reported that the quality and cost of care for these surgeries varied significantly by region and by hospital, and was true for both the care received in the hospital and for post-acute care outside.

The variation, they said, is due to the way Medicare pays for this care today, spread among multiple providers, with no single entity accountable for the total patient experience.

Care can be fragmented, they wrote, which leads to adverse outcomes.

Here are the key takeaways from the final rule:

  • the CJR model seeks to incentivize Medicare providers and suppliers to work together to improve the quality and reduce the costs of care for patients undergoing lower extremity joint replacement
  • the acute hospital where the procedure occurs will be accountable for aggregate Medicare expenditures and the overall quality of related care
  • the model will include participant hospitals located in 67 Metropolitan Statistical Areas (MSAs) throughout the country
  • acute hospitals paid under the Inpatient Prospective Payment System (IPPS) and located in the selected MSAs will be included in the model, with the exception of hospitals currently participating in Model 1 or Models 2 or 4 of the Bundled Payments for Care Improvement (BPCI) initiative
  • depending on the hospital’s quality and aggregate spending performance, the hospital may receive an additional payment from Medicare, or need to repay Medicare in the second year if spending exceeds targets
  • hospitals will need to work with physicians and post-acute care providers, such as home health agencies and skilled nursing facilities, to ensure patients get the care they need

This is in contrast to what I reported on in July, when I said that a former CMS official was cited in the Freeman article as saying that mandatory bundled payments for hip and knee surgeries would shutter one in four skilled nursing facilities and trigger “demand destruction in areas such as diagnostic testing, hospital stays, and avoidable readmissions.”

Whether or not this final rule will do what the authors of the Health Affairs article says it will do remains to be seen, but judging by past CMS programs to affect quality and costs, this may be wishful thinking on the part of the authors.

The insistence that one more new initiative, or more incentives, or one more new model or new rule will change the way health care is being provided in the US, just goes to show that until we adopt a single-payer, “Medicare for All” system with less rules and less incentives, some people will continue to game the system, then we will see a radical change in the American health care system.

And if workers’ compensation follows changes in health care under Medicare, especially how it determines reimbursements for hip and knee surgeries, which are also common to workers’ comp, we can expect to see issues in workers’ comp.

Alternatives must be considered to an ever expensive and poor quality of health care for workers’ comp. That alternative is medical travel.

Challenges Remain in Physician Payment Reform

Following up on my post yesterday about shared savings, John O’Shea writes today in the Health Affairs blog, that challenges remain with regard to physician payment reform, now that President Obama has signed the Medicare Access and CHIP Reauthorization Act (MACRA) in April.

MACRA repeals the Sustainable Growth Rate (SGR) mechanism of updating fees to the Physician Fee Schedule (PFS).

The SGR has been blamed for causing instability and uncertainty among physicians for over a decade, and that led to 17 overrides of scheduled fee cuts, at a cost of over $ 150 billion.

The passage of MACRA, O’Shea wrote, raises new questions about where the US health care system is headed in the post-SGR world of payment and delivery reform.

Yet, before MACRA was signed into law, HHS Secretary Burwell announced a major initiative calling for 30 % of Medicare payments to be value-based through the use of alternative payment models (APMs) by 2016, and 50% by 2018.

HHS also set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016, and 90% by 2018.

O’Shea reported there are reasons for caution. These policy changes, following calls to move from the current volume-based, fee-for-service (FFS) system to a value-based system that pays for patient outcomes, rather than for individual services, present major challenges to achieving the goal of value-based health care, the goal of any real health reform initiative.

One of the APMs O’Shea discussed is Value-based purchasing (VBP), which is the concept behind APMs, includes a broad set of performance-based payment strategies that attempt to use financial incentives to influence provider performance, such as the Shared Savings Program mentioned yesterday.

Another APMs is the Merit-Based Incentive Payment System (MIPS) [don’t you just love how the government comes up with these abbreviations?], a modified FFS system, which is basically a Pay-for-Performance (P4P) program.

The overall early results of these initiatives, as well as possible flaws, make the long term viability of these models uncertain.

With regard to P4P programs, a 2014 RAND report looked at 49 studies examining the effect of P4P on process and intermediate outcome measures, and found that the overall results were mixed, and that any identified effects were relatively small.

According to the lead author of the study, Cheryl Damberg, “The evidence from the past decade is that pay for performance had modest effects on closing the quality gap.” A basic flaw in the model is the reality that meaningful patient-centered outcome measures remain elusive.

ACOs, as I wrote about yesterday, are another APM; and O’Shea reported that their ability to generate savings to share with participants is so far not encouraging. He points to early results from the Pioneer ACO program that determined that of the 23 ACOs that participated in 2013, only 11 earned any shared savings, which totaled about $41 million. Six ACOs lost a total of $25 million. The results from a similar study in 2014 showed improvement, but the long-term outlook is still unclear.

What is the impact on the practice of medicine?

What O’Shea found was that physicians currently labor under an increasingly burdensome and often meaningless number of reporting requirements that take time away from patients, and fail to help them improve quality of care.

Accordingly, a commentary O’Shea cited from the New England Journal of Medicine said that, “the quality-measurement enterprise in US health care is troubled.”

A recent CMS report, O’Shea mentioned, said that 40% of Medicare providers will face 1.5% cuts for failing to submit data to the Physician Quality Reporting System.

Because of this, many public and private payers are tying larger amounts of provider payments to a growing number of largely meaningless measures.

O’Shea said that there are two areas of concern, given the plethora of payment and delivery reform initiatives: the administrative burden on physicians, and the push towards greater consolidation.

Nearly half, or 46% of doctors who reported said that they felt burned out in 2014. A main reason cited by the physicians was the increasing administrative burden.

What does the mean?

Well, having slogged through an online Health Care Quality course as part of my MHA degree program, the myriad abbreviations mentioned in Mr. O’Shea’s article does not surprise me. CMS and HHS has for years developed all kinds of initiatives and programs to influence and alter behavior of all stakeholders in our health care system.

As “Uncle” Walter Cronkite once said, “America’s health care system is neither healthy, caring, nor a system.” And that was before the passage of the ACA.

But for the purposes of this blog, and in keeping with the point of the last article where it was said that what happens in health care affects workers’ comp. then I think you can agree that these initiatives and programs, while well-meaning, may make things worse in the future, but not because the idea behind the ACA or the law itself is bad, but because we Americans cannot do anything right until we try everything else, a la Winston Churchill.

If that is the case, then believing that by doing the same things over and over again, that by following everyone else off the cliff of unregulated, employer-based, multi-payer health care, and by not opening the workers’ comp system to real alternatives, especially for surgery, then nothing will ever change.

We will continue to see more new initiatives and programs from CMS, and the results will be dismal, and the impact on workers’ comp will be felt eventually. That is, unless you open up your minds to new ways of thinking.

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I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com. Share this article, or leave a comment below.

Shared Savings ACO Program reaps the most for Primary-care Physicians

Yesterday, I reported that workers’ comp industry personnel believed that ACOs are a big driver of cost shifting under the Affordable Care Act. In that same article, I mentioned that anything that has a significant impact on healthcare, will also impact workers’ comp.

So, when I found an article on Modern Healthcare this afternoon that indicated that primary-care physicians are reaping the most from a CMS program under Medicare called the Shared Savings Program, I thought that this needed to be brought to light.

Today’s article seemed to contradict the impression the original article had on healthcare costs.

The article, by Melanie Evans, New York bureau chief for Modern Healthcare, stated that for the second year, CMS had awarded bonuses to 1 in 4 ACOs working under a Medicare model intended to spur providers to deliver lower-cost care.

These ACOs will share $422 million out of the $833 million they saved the government in 2014.

A review of disclosures by ACOs participating in the program found that primary-care doctors are benefiting the most.

The incentives that are paid directly to providers can be a powerful way to change the practice of medicine, Ms. Evans writes, as doctors alter their behavior to earn payouts.

Yet, research on the incentives has yielded mixed results.

Dr. Kavita Patel, managing director of clinical transformation at the Brookings Institution’s Center for Health Policy said, “We don’t have a good distribution model for ACO savings.”

Last week, the Obama Administration announced that 97 of the 353 ACOs earned bonuses in 2014, and most of them were in the Medicare Shared Savings Program.

Among the first cohort in the program, those that were specifically singled out as primary-care physicians, were equally likely to see no bonus as they were to earn payouts.

Participants said that they only distributed rewards to individuals after recovering expenses and investments. A few said they would hold some benefits in reserve in case of poor performance in the future, but most are reinvesting a percentage and dividing the rest among the physicians, specialists and hospitals.

One-third of participating ACOs said that they pass along a share of their award to primary physicians, as much as 80% in some cases. Those that disclosed detailed breakdowns of their allocations said 46% would go to primary physicians, on average.

Those who singled out specialists and hospital had lower percentages, 20% and 27%, respectively.

What does this mean?

If we are to believe that Medicare’s program for shared savings will lead to lower-cost care from primary physicians, then it is not likely that ACOs will lead to cost shifting, as the first article reported. And if what happens in healthcare impacts work comp, then this shared saving program should do the same if adopted by the workers’ comp industry.

Who is right, and who is wrong? I think neither article has been able to answer that question.

Your thoughts?

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I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com. Share this article, or leave a comment below.