Michael L. Millenson is frustrated at the pace of change in reducing medical errors and adopting evidence-based care. Ten years after writing the ground-breaking book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, and six years after discussing it in his first Managed Care interview in 1999, Millenson says that progress has been slow and piecemeal.
Clinicians need to more fully embrace information technology to avoid being swamped by information overload. The good news for health plans is that emerging plans that are moving away from price competition to promoting and managing high-value care will have a unique opportunity to reinvent themselves as trusted intermediaries.
As president of Health Quality Advisors, Millenson focuses on patient empowerment, e-health, and quality improvement as a consultant to health plans, corporations, consumer groups, and trade associations. Millenson also holds an appointment as the Mervin Shalowitz, MD, Visiting Scholar at Northwestern University's Kellogg School of Management. A former reporter for the Chicago Tribune, where he was nominated for a Pulitzer Prize three times, he was a consulting producer for the series Remaking American Medicine, which aired nationally on public television in October. He spoke recently with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: If we're moving toward the end of employer-sponsored health care, how will health plans have to reinvent themselves?
MILLENSON: Most major American corporations are much less stable today than they were in 1994, when the managed care backlash first erupted. Nobody working at a large corporation today thinks the company is immune from a serious crisis or even going out of business. So how can they think their pensions or health benefits are safe? Therefore, the idea of establishing a relationship with a trusted health plan is much more attractive today to many more workers than it was back in 1994. The Clinton health plan proposed regional accountable health plans that people could join on their own or through their employer. It was a good idea. We should move to accountable health plans that aren't tied to insurance, so people can choose their plan and benefits. It would free health plans to be creative in improving care. Health plans are doing a host of wonderful things that nobody knows about to improve management of chronic diseases and provide better evidence-based care. Plans don't communicate well with the general public, maybe because they're fearful that they won't be believed. If we go to an accountable health plan framework, the energy and entrepreneurial creativity that health plans are displaying will be out there for everyone to see.
MC: How should care be paid for?
MILLENSON: I believe the system should and will eventually move toward what has been called fee-for-benefit. When the term was coined by George Diamond, MD, of Cedars-Sinai Medical Center in Los Angeles in the early 1990s, it received a sliver of attention and then faded away. I think it ought to come back. Here's how it would work, using the example of coronary artery disease: If effective care could be provided through angioplasty for a certain amount of money, and the patient insists on bypass surgery, the amount the insurer would pay for the procedure would be capped at the cost of the most effective care; in this case, angioplasty. I believe this is where managed care eventually will move. Americans would not accept a managed care plan that paid zero for the bypass, but a managed care plan that reduces the copayment for patients who choose evidence-based treatment is something very different. Plans would pay a much smaller portion of the bill for patients who prefer surgery not because they are rationing care, but because that option reflects the plan member's personal preference rather than the medical evidence. Of course, a plan member can choose to buy a bypass with his discretionary income as opposed to having a free angioplasty, but that's an individual choice. This country is very much built on the principle of paying more for the privilege of individual choice. We're never going to be like Britain and not allow choice.
MC: Such a system would require health plans to have bulletproof data on effectiveness and to rebuild credibility among physicians.
MILLENSON: That's exactly right. Health plans would need to be trusted intermediaries and to clearly take stands based on the evidence. I believe that's a good thing. Too many health plans have bought into a definition of consumer-driven care that is simply an overblown version of cost shifting with unreasonable assumptions attached.You cannot expect someone who is sick and anxious and who uses the health system infrequently to be able to deal with sophisticated information or figure out treatment options alone. You need an intermediary to help out the patient and her family, even if you decide to call the patient a consumer. The health plan can help the consumer understand the choices by championing tools that provide evidence-based information customized to each individual patient's clinical signs and symptoms. They also need to provide tools to deal sensitively with the emotional and spiritual issues that often go hand-in-hand with illness. Consumerism in health care is important, but the information needs of a person coping with illness are not the information needs of a consumer excitedly shopping for a new refrigerator. Health plans need to provide information that goes beyond spreadsheets and brochures. Information must be factually sound, personalized in content and emotionally sensitive to the needs of the people using it. One example is harnessing evidence-based factual information to videos or testimonials from women who have decided on a lumpectomy versus a mastectomy, or men who have decided on a particular prostate cancer treatment. Different individuals have different ways of absorbing information, and we need to surround people with information presented in all sorts of different ways, but all of them focused on enabling patients to be true partners with their physician.
MC: How can a health plan serve as a trusted intermediary if part of its essential structure is preferred contracting with certain providers? Do they have to get out of that business and direct patients only to clinicians who most consistently get the best outcomes as opposed to those who could offer them the best deal?
MILLENSON: That is a critical question. Managed care started down the value path, but gave up when confronted by large employers who wanted broad networks to keep employees happy. Now, most consumers presume that their doctor should be in their health plan's network. For health plans to survive in an age where outcomes information and adherence to evidence will be transparent, they'll have to demonstrate that the clinicians they contract with provide exceptional value, not just low prices. The question is whether the large national health plans, which are led by individuals who understand these principles, believe in them enough to construct their networks that way. The other choice is to continue to use the rhetoric of value in public, while down in the trenches, the sales force concentrates on selling a broad network and the contracting managers concentrate on driving down provider prices. If health plans don't meet this challenge, I think they will find themselves dis-intermediated. It's unfashionable but I think we could see the managed care backlash pendulum swing completely the other way. That won't happen, though, as long as plans try to rehabilitate their reputation by following the chimera of price transparency offered by so-called consumer-driven health care. Health care prices are an illusion, because total cost is a function of price and units used. In health care, as the first PPO "discounters" quickly discovered, there are a thousand ways to change the number of units used. Do I keep you in the recovery room an extra half hour? Which anesthetic would you like? It makes bargaining for a car look cut-and-dried. The ultimate issue is not price, it's value. Many health plans are working hard to improve value, but a lot of them haven't believed that the average member can understand what they're doing. Health plans that are adept in using information to purchase and manage care and to help their members manage their own care need to be proud of what they're doing and make those actions the centerpiece of their sales strategy.
MC: In Demanding Medical Excellence, you wrote that tens of thousands of patients died or were injured each year because readily available information was not being used to guide their care, and that the toll went into the hundreds of thousands when lives lost to preventable medical mistakes were included. Is that still true today?
MILLENSON: Unfortunately, yes. The health care system today is more quality oriented and is safer than it was ten years ago, but by any reasonable measure except the ostrich-like insularity of those of us in health care, progress has been agonizingly slow. What I wrote about patients unnecessarily hurt and killed is precisely as true today as it was in 1997, although my estimate of the casualties was conservative. The bottom line, though, remains the same: The only barrier to saving these lives remains the willingness of doctors and hospital administrators to change. In the years since, we instead went through a managed care backlash, where all fault fell at the door of insurance companies. Then, as we do every decade or so, we went through a malpractice crisis, when all blame fell on the lawyers. Today, we have a new twist, with the system's problems being blamed on patients, because they don't have enough of an economic incentive to shop right. That's given rise to the notion that we'll fix the system through health savings accounts and health reimbursement arrangements, which all available research evidence shows just aren't adequate. What we really need is a health care information revolution that takes the right amount of power away from providers of care and gives it to consumers of care, a term that includes individual patients and the employers and plans who pay for care.
MC: What is the right amount of power?
MILLENSON: It's the amount necessary to turn the task of consistently providing safe, evidence-based care from a fifty-year project without any discernable urgency into a five-year crash project with a real deadline. The right amount of power is the power it would take to change professional norms so that doctors who failed to wash their hands before touching patients — something we've known is wrong since the 19th century — would be as professionally scorned as surgeons who forgot to put on gloves before going into the operating room. Doctors who scorn evidence-based guidelines as cookbook medicine should be seen as eccentrics, not protectors of professional prerogatives. Every hospital I wrote about ten years ago that was a leader in using guidelines appropriately allowed physicians to override those guidelines as long as they could provide a satisfactory explanation. "I was not trained to practice that way," is an excuse, not an explanation. Rather than arguing about "cookbooks," we need to have a revolution where physician autonomy and physician accountability are balanced in a way that promotes a partnership based on the doctor's knowledge and experience as well as on the evidence of the literature and the patient's preferences. When we know what to do best for patients, we have an ethical and financial obligation to do it and we need to consistently act on that obligation. That's where managed care can play a constructive role. Many medical directors have a great deal of knowledge about this area; the time has come for them to speak out about evidence, make alliances with academics and consumer groups, and explain to their peers and the public why pay for performance needs to be done in an objective way. Only doctors who are respected as objective sources can make that argument.
MC: Why is change taking so long?
MILLENSON: The system is deeply flawed, even though it is populated by smart people who are trying hard. They don't see the flaws in their own work. Another problem is that organizations that are the greatest campaigners for change are too worried about alienating physicians. The status quo is outrageous and unacceptable. The Institutes of Medicine and other organizations say the system is broken, but only on a generalized level. We don't have the equivalent of Mothers Against Drunk Driving naming the people who died or were hurt at a particular hospital. Instead, we fall back on the system-error argument, which is technically correct but deeply flawed morally.
MC: Can you give an example?
MILLENSON: Imagine if United Airlines' CEO refused to buy collision-avoidance equipment because he felt it reflected unfairly on the competence of his pilots. If there was an avoidable collision, we would hold United Airlines legally liable, not to mention the moral indignation of airline passengers. The response to United's CEO would be, "We don't care if you're well intentioned. You were wrong, people died, and you're responsible." We have nowhere close to that degree of accountability in health care. My question to those who counsel patience and plodding change is this: At what point does the failure to adopt solutions go from being a system error to something for which we should hold individuals culpable? What are the consequences when a hospital administrator knows that a computerized physician order entry (CPOE) system will prevent errors, but chooses instead to invest in an obesity clinic? Nobody in health care is calling individual institutions or their executives on the carpet for the failure to change.
MC: If doctors and hospitals can't or won't change on their own, can employer efforts like the Leapfrog Group help improve care by directing their business to providers who employ best practices?
MILLENSON: The Leapfrog Group is a great effort that started out with Fortune 500 companies telling hospitals to make certain changes by a certain deadline or lose their business. But then they dropped the deadline. Not surprisingly, the impact of an ultimatum without consequences isn't very large.
MC: They put down the gun. If private payers won't force change, what about the federal government through CMS?
MILLENSON: The Medicare program has been a positive force under former CMS administrator Mark McClellan. The have begun providing understandable, standardized data to compare hospitals around the country, and they are constantly expanding the scope of the measures. I believe that Medicare's eventual move to paying for performance is the political action that will tip the entire system. While they currently have a pay-for-performance pilot program for hospitals, they need additional legislative authority to adopt it for all hospitals, since the Medicare legislative language contains certain limits on their freedom.
MC: Thank you.