Demanding Medical Excellence with Michael Millenson, President, Health Quality Advisors LLC

Episode 126

Outcomes Rocket - Michael Millenson

Demanding Medical Excellence with Michael Millenson, President, Health Quality Advisors LLC

: [00:00:01] Welcome to the Outcomes Rocket podcast where we inspire collaborative thinking, improved outcomes and business success with today’s most successful and inspiring healthcare leaders and influencers. And now your host, Saul Marquez

Saul Marquez: [00:00:18] Welcome back once again to the Outcomes Rocket podcast where we chat with today’s most successful and inspiring health leaders. I want to thank you again for tuning in and I welcome you to go to outcomesrocket.health/reviews where you can rate and review today’s podcast because he is a friend and an outstanding contributor to Health. His name is Michael Millenson. He’s the president of Health Quality Advisors. He’s a adjunct professor Associate Professor of Medicine at Northwestern University Feinberg School of Medicine. The contributing editor at the G Health Care Blog a board member of the American Medical Group Foundation and he’s done so many things in his career to be a contributor and health care a specialty in policy and so I’m just so privileged to have him on the podcast today. Michael I want to welcome you and also open up the mic for you to fill in any of the gaps in that intro. So happy to have you.

Michael Millenson: [00:01:16] Well I’m delighted to be here, Saul. And of course happy with the entire focus in this podcast on thought leadership. Just by way of background I began as a reporter covering health care for the Chicago Tribune and after awhile got to know too much about the difference in what happens in meeting rooms where they talk to journalists and have big meetings and in the front lines of care and decide to go out and spend my time. More towards the front lines. I wrote a book called demanding medical excellence doctors and accountability in the Information Age back in 1997 and talking about evidence based medicine informatics in great detail Patient Safety Quality and Outcomes improvement patient centered care and changing how we purchase care and really became activated. Now Mitchell Levy who’s a consultant I work with startups to major corporations in the policy world I do a lot of white papers and it involves a lot of policy discussions and do some original research and try to act as a patient advocate as well. All of that is connected by trying to make the care delivery system better. So while some folks focus on insurance whether we’re going to have single payer or some other god knows what variation. I focus on what happens when you get into the care system. How can you get better care.

Saul Marquez: [00:02:37] That’s really interesting Michael and listeners if you haven’t taken a read of Michael’s book demanding medical excellence the listenership of this podcast fits the bill for who needs to read it. Any stakeholder in health care really whether you be a provider a patient industry executive. This book is for you because Michael really takes a deep dive into just questioning some of the processes the system that the system currently uses and so Michael I definitely took a read and I recommend it to all the listeners. What do you think today. Out of all the things hotting in medicine is a hot topic that should be on every medical leaders agenda today.

Michael Millenson: [00:03:17] Well I think to me one of the most pressing needs that’s coming to fruition is how we’re changing the relationship between the care system and patients or individuals because of changes in economics of the way people are paid. JD technology and really sort of social changes and I’m tried to put this into a conceptual framework that I call collaborative health and that is not collaborative care which is when healthcare workers all sort of collaborate together from different specialties. It’s not a patient centered issue which is what happens when you have control of the patient. It’s what happens when for your well-being and for sickness care the individual has a choice who they collaborate with elaborate on that for a moment.

Saul Marquez: [00:04:07] Please.

Michael Millenson: [00:04:08] That it used to be that the care system controlled everything. And now this is kind of like medicine. Martin Luther a moment when the priesthood had to open up the secrets to the masses. And what we have now is you can go online and find diagnostic information treatment information a lot of other information is just as personalized and accurate often. Not always of course as your physician at the same time normally clinical folks in public health and other areas are trying to reach out in the social determinants of health. And what you have is this entire continuum from well-being to really being sick where all sorts of folks who never were part of the healthcare system before were now part of that system and where the individual has far more information and good information independently of their doctor than they ever did before. And that’s going to require a lot of adjustment to relationships and relationships are really difficult. It’s not just the matter of turning on your iPhone smatter responsible for work but how we really differently how do we restructure the care delivery system to take into account all these changes.

Saul Marquez: [00:05:27] That’s really really interesting and very thought provoking. You’re about to say something else. I don’t want to interrupt. Go ahead.

Michael Millenson: [00:05:32] And the thing is that I’m really against simplistic answers so I don’t believe that the patients are going to be the CEO of their care all the time and I don’t believe that on the other end that the care system is going to be completely different. So patient centered there’s a continuum. And so sometimes you’re the CEO of your care and sometimes you’re really sick and you just need empathy and caring and somebody to take care of you no matter how much knowledge you have no matter how much expertise you have you’re vulnerable you’re sick you in the kingdom and the sick. But what we’re having is it continually changes and it all. I’ll give you an example. You could today walk into a brick and mortar doctor’s office that’s run by Google’s parent alphabet and it’s called city block. You may be able in a few months to then open up your medical record on your Apple Phone your medical record from its usual care provider. You’ll get some sort of referral and maybe you’ll get your diagnosis from an AI application called Isabelle which has a web based application for patients as well as a diagnostic application for doctors. You can then perhaps be Monnerie of home with some sensors in your apartment that are placed there by a division of Best Buy a retailer and maybe if you need food that can be delivered by your health plan Humana continuum with care of nontraditional actors. It is unprecedented simply unprecedented. It’s being tied together by technology. It’s being tied together by payment changes and it’s being tied together by cultural changes that really are the greatest we’ve seen in health care since apartheids made his first HOUSECALL.

Saul Marquez: [00:07:30] Love it Michael. And you know ever since the first time we met you never failed to put things in a very candid perspective that forces the listener or the reader to urge people to interact with that kind of think. And so you take us through this continuum of care that includes Google and Izabel and Best Buy and Humana and you also mention that at the same time you also know that these changes are not going to happen overnight. And so what do you think organizations and health leaders need to be focused on in order to ensure that number one they don’t get disrupted. And number two that they leverage these new concepts and new technologies and ways of working.

Michael Millenson: [00:08:14] So when I talk to health care leaders I find that it’s very difficult for them to win vision a situation where they are not in control they can get up to the part where maybe they’re partnering as equals but what they can’t get kind of a mind wrapped around sometimes is that the individual can have health care and wellness relationships that are very significant but they don’t include the traditional care system. So what I tell them is that to think that the old saying nothing about me without me in the way of the healthcare system telling patients we understand we’re going to be patient centered. They should think of it as the patient saying to them nothing about me without me but sometimes without you.

Saul Marquez: [00:09:03] I love it.

Michael Millenson: [00:09:04] That’s the key. This is not about you. This is about a broader change and one of the examples I gave in an article I wrote to the BMJ this past summer on collaborative care which was actually an editor’s choice I was really quite thrilled by that nice was the example of policing right. You have community policing where they’re reaching out the equivalent of hot spot and they go into the community to try to do prevention if something happens they’re using digital technology to figure out where to send the police and all the rest of this and that doesn’t mean that the cop on the beat the guys in the car in the neighborhood are not really important when bad things happen. Right. What was means is sometimes policing happens without you and you’re being decision mediated somewhere or the continuum. Some of the time and that’s what’s happening in health care. Not that if you’re really sick and you’re in the hospital for cancer or a heart procedure you don’t need the traditional care system. Be patient centered but there’s a continuum and there’s a change in a relationship.

Saul Marquez: [00:10:09] I think that’s a good call.

Michael Millenson: [00:10:10] The advice that I would give the reason I brought up that example of nothing about me without me but sometimes about you. It’s a way for healthcare leaders to think about what it changed relationship leaves out how are they going to relate to other actors. What is their relationship going to be with a best buy or with a city block or with other retailers or other entrepreneurs coming in. And also to think how they’re going to have a relationship with the patient when an individual is not a patient that individual has their medical record independently of you. Importable how are you going to have a new relationship and what are the other kind of sayings that I heard once in relationship to accountable care organizations which I liked a lot. You know Medicare a CEOs on Reika a Medicare manager like an HMO. They can’t have a financial penalty if you don’t use their Knebworth right. So you have to be attractive to the patient and the same is greener pastures not higher fences. I like that a lot. So if you’re a leader preparing for a future that’s coming relatively quickly where at least part of the time you not as central to your patience as he used to be. And yet due to payment changes you need to be part of an ongoing relationship. How are you going to have greener pastures when higher fences don’t work anymore and that’s what I really have been talking to a lot of folks about how do you make that happen in the front lines of care as opposed to simply you know as a conceptual matter.

Saul Marquez: [00:11:57] Yeah you know it’s a really great perspective Michael and with Macra and MEPs sort of being part of the legislation and I think it’s a reality that volume to value is here to stay.

Michael Millenson: [00:12:09] When you look at macro one of the things that’s interesting about it this year is a bipartisan piece of legislation overwhelmingly bipartisan in the legislative language not simply in the regulations in the legislative language has certain patient centered requirements for things like shit or decision maidenhair coordination things like that. So that tells you that these kinds of concepts have very strong policy support. At the same time when you go to digital health because that involves entrepreneurs and a lot of us startup capital a lot of activity of profit making entities. That too has a lot of congressional policy support. And finally when you get to Social Determinants of Health because we as a nation are not investing in the public health infrastructure the private sector is clearly going to pick up more of that load. So whether you’re looking at Medicare policy whether you look here broader policy trends or whether you’re looking at what’s happening culturally this kind of new collaborators new ecosystem health care is starting to happen. It’s just not totally visible yet but you can see the pieces moving into place now.

Saul Marquez: [00:13:27] Without a doubt. And so you’ve been in health for quite some time Michael and from when you started as a reporter and health to now couple of decades. What would you say some of the mistakes that you’ve seen happen that health leaders could learn from and not repeat today.

Michael Millenson: [00:13:43] Well Bill Gates famously said in one of his books that we tend to overestimate the speed of change in the short term and underestimate it in the long term. Witness knows that is absolutely true in healthcare. And I think the biggest challenge in healthcare for health care leaders often is distinguishing between fast moving traffic and slow moving icebergs. And you can get run over by both. But as a manager you need to know which is coming more quickly.

Saul Marquez: [00:14:12] That’s so great.

Michael Millenson: [00:14:12] And still I think that there’s adaptability is incredibly important without getting caught up in jargon that simply isn’t true. So if in fact you got caught up with the jargon you would have thought that all employers were buying based on quality and outcomes. Twenty years ago or 15 years ago or whatever right to be everybody top well but it was just a few people doing it and it really hadn’t caught on. At the same time if you ignore the iceberg you can look and say a fee for service is still overwhelmingly what’s here. I don’t have to worry about value based care and that would be to ignore what’s happening to the federal budget and private corporation budgets for health care. I don’t understand that there’s this consensus about how we’re going to change the payment system that crosses ideological lines that cross the government and private sector lines is simply so deep that you better take that into account. Are you going to get run over. So I think that’s the real challenge is understanding when to adapt quickly and with perhaps adaptability can take a little longer.

Saul Marquez: [00:15:20] Yeah that’s pretty interesting what you say up to this point Michael in in your observation of the health system as well as your experiences as a consultant and a writer what would you say one of the proudest medical leadership moments that you’ve experienced to date is.

Michael Millenson: [00:15:37] I would say in sort of two different capacities as a writer and author I’ve had individuals physicians and others come up to me at meetings where I just happen to be a speaker and tell me that reading demanding medical excellence change what they did with their career change what they did with their life made them more cognizant and active about improving quality and improving patient safety and really making that part of their life’s mission. And that’s both extraordinarily gratifying and extraordinarily humbling. As a consultant I worked with some physician colleagues where we put together an accountability audit for a hospital and this is perhaps 10 years ago now before information systems were sophisticated but we showed this hospitals what their quality looked like to outsiders if you really looked and what they were saying about it to themselves. And the difference in the medical staff of that hospital the medical executive committee of about 10 people or so looked at us and virtually without dissent said we didn’t know. What can we do to make this better. We’re not training quality improvement. That’s not what they’re training about in medical school. We believe that is help us make it better and to have the opportunity in a real situation to help a major hospital improve its care. It was again very gratifying and humbling.

Saul Marquez: [00:17:08] Now Michael there’s no doubt you’re making waves out there with your thought leadership and you know even on the podcast for instance. We always ask our guests for but they recommend in your book come up a couple times. And so no doubt you’re making an impact and that’s definitely something to be proud of than just super thankful that you made it on the outcomes rocket. Because we are very focused on removing silos to improve health outcomes and so the alignment could be better.

Michael Millenson: [00:17:35] That’s really important to improving the silos and you know when I wrote demanding medical excellence. What shocked me was the degree to which evidence doesn’t change behavior to which there are silos to which there is inertia in the health care and really almost everyone in health care gets into health care to help people. People do not say what shall I be a hospital administrator or an investment bank. That’s not the choice right. And they’re not getting there to make as much money as possible you know should I be a nursery a hedge fund manager. Right. That’s not what is. People are making. They really care for a variety of reasons there’s enormous inertia. And when I demanding medical excellence I vastly overestimated how quickly change was coming because things were so obvious it was so obvious that computerized clinical decision support could mean care better. And yet it is just now happening. It was obvious that we did change how we bought care because fee for service was not working and yet it’s just happening. It was obvious that we needed to pay more attention to the patients preferences and values. And yet it’s just happening. And so the inertia in the health care is often overwhelming and he really needs an earthquake often to change. And that earthquake is changing to value based payment and that earthquake is health information technology that is so pervasive that it can’t be ignored. Right because it’s coming from the outside. Now this is a service offering to give you your medical records then epic says no we’re going to do ours. This is Apple’s doing it. This is a pharmaceutical company offering to give you more information on cancer care. It’s IBM Watson making an alliance with the American Cancer Society. Right. So it forces from outside healthcare that are permeating health care and causing it to change. That has a good side and a dangerous side. But it is certainly a force for change that will not be resisted and cannot persist.

Saul Marquez: [00:19:49] Totally agree. You know just thinking through that analogy that you gave us might call the slow moving glacier is no doubt underestimated. And we’re starting to see a lot of those changes happening now. Tell us a little bit about an exciting project or focus that you’re working on as it relates to that.

Michael Millenson: [00:20:06] I’m trying to really go out and do a lot more writing and speaking and perhaps looking at projects in the field the front lines that represent collaborative health. I was speaking to a pediatric hospital executive the other day about some of the things that they’re doing where they’re really letting patients not only be in charge of the care where they can and giving them information or even letting patients run clinical trials that the parents of pediatric patients. And so I think that to me what’s exciting is to show that change is happening in real life not just in theory. To look at the pieces and try to put them together in a way that helps people see that a real paradigm shift is possible. And we all tend to think in an easy categories right it’s all about technology or all about social determinants. It’s all about a lot of different things that come together at different times. And one of the things that needs to be cherished is the fact that we as people have different needs at different times and a collaborative relationship will be flexible. I call it the yes dear principle. Sometimes you make a decision collaboratively with all the factors being weighed in great detail and you have discussions and great kind of debate over what to do. And sometimes you just say yes dear is and doesn’t mean that you don’t have a collaborative relationship. I mean sometimes one person makes the decision sometimes the other person makes decision sometimes you make it together. Sometimes you bring in someone from outside who knows more than you know. And so that’s real life and that kind of real life is what’s coming to the health care system in a lot greater volume and depth than before. And it’s a little difficult. We used to controlling all information for somebody to say you know what I’ve got this piece of information that came from the remote sensors in my mother’s living room and those came from a retailer and I got this data that comes from online I’ve got you don’t know what’s reliable and what’s not and you’ve got to work with that. But that’s the world we’re coming to. And I want to say that one of the things I’ve talked about for adapting to this world and it is really important is the principles of shared information shared engagement and shared accountability. And I cannot overemphasize how important trust is going to be in this new world. Right. Because I’m different players. What are their obligation to the trust. And if the traditional care system or anyone for that matter the new players as well wants to be trusted. I think they need to share information openly. That means open notes. But it also means sharing with other people I want you to share with us whether it’s my patients like me group or whether it’s a retailer or an entrepreneur. It means sharing engagement. I want you to look at my online community. You need to do that but at the same time you need to engage with me in a much different way not simply to manipulate me into compliance but actually engage with me shared accountability can be really difficult. Who’s responsible for privacy and security and communication gaps and all the rest right. Because if I’m going to paternalistic systems then daddy is responsible. The traditional care system. The patient derived from the word to suffer. You’re the doctor derived from the Latin term to teach you teach. I suffer. We all know our jobs right. When you have all sorts of different people what then IBM Watson is not a doctor. What’s their obligation. Medtronic is working on devices that interact directly with consumers what’s their obligation when alphabet sets up a doctor’s office and has all sorts of other kinds of things are not traditional what’s their obligation. What about privacy. What about a lot of other things. And you know everything’s going right and you have happy stories of empowerment. That’s great. But this is health care. Things go wrong. People get hurt sometimes seriously. It may not be anybody’s quote unquote fault but somebody is going to get blamed. And how do we deal with that. How do we set up new systems. I think if we if we work on trust if we work on openness of information openness and engagement and openness and accountability the responsibility is we at least lay the foundation for lasting change. It does not get caught up in backlash in legal actions and all sorts of other complications that can really hurt the ability of the health care system to improve care for everyone.

Saul Marquez: [00:24:51] It’s a really interesting focus Michael and here definitely at the forefront of thinking through some of these things so listeners if you have any thoughts questions or just want to bounce ideas off of Michael I know he’s very collaborative and at the end of the podcast we’ll be including his contact information at the very least the linked in profile where he could reach out to him because definitely and an individual worth checking in with and chatting with. So Michael let’s pretend you and I are building a medical leadership course and what it takes to be successful in medicine. It’s the 101 or the ABC of Michael Millenson. So I got a quick syllabus that we’re going to do with four lightning round questions followed by a book and a podcast that you recommend to the listener as you’re ready.

Michael Millenson: [00:25:37] I’m ready.

Saul Marquez: [00:25:38] Alright. What is the best way to improve health outcomes through policy.

Michael Millenson: [00:25:44] We need to pay people in a way that takes into account measurable quality indicators particularly on patient safety but also in other dimensions and we need to have the pay to be significant enough to get folks attention the same time. You can’t focus too much on the individual doctor. This needs to be in a way that is a collaborative and lets people improve systems of care. That is really difficult to do because when it comes to politics everybody wants to be a winner. Nobody wants to be a loser. If I’m losing money then the system must be broken because I know that I’m above average. So that’s what makes it difficult.

Saul Marquez: [00:26:21] The Great One. What’s the biggest mistake or pitfall to avoid.

Michael Millenson: [00:26:24] Under estimating the difficulty of cultural change. The people who will fight to prevent change are not evil. They honestly believe in the status quo and you cannot underestimate the power of inertia particularly when somebodies pocketbook is at stake. When I wrote demanding medical excellence I was chastened by how many changes I had thought would have happened and it hadn’t happened that I’d written about when I was a journalist and ten years later. They hadn’t happened. And then I do the history. Twenty years ago people said they were going to happen 30 years ago people said they didn’t happen. And I came up with a way to categorize the influence of economic factors grab them by their wallets and their hearts and minds will follow.

Saul Marquez: [00:27:16] Well said my friend. Well that’s it. I love it. I’m glad you went back to that one. That’s a good way to summarize it. So obviously relevance is buy you create change by being able to create incentives. How do you stay relevant despite constant change.

Michael Millenson: [00:27:35] I think the way to stay relevant is to be widely read both in healthcare and elsewhere. We tend to be very focused on our own silo. We don’t see how something that’s happening in the FDA may be like what’s happening in CNS and the V.A. and in policing in the Army in sports. All those different areas are often subject to the same cultural forces that are subject to health care. In fact my book was used in policing for evidence based policing. And so I think that’s pretty cool. It was pretty cool always stay relevant is by staying intellectually curious and open two other trends that are not perhaps in your confliction.

Saul Marquez: [00:28:20] A great call out and what’s one area of focus that should drive everything in your health work.

Michael Millenson: [00:28:26] May care better and safer make care measurably better and safer. Nobody is letting harm happen to patients on purpose and nobody is providing care. That is not the best possible care on purpose. And yet when there is ample medical literature on how to make care safer and we don’t get around to doing it because there are other priorities when there is ample medical literature on individual procedures. Cancer and heart care a lot of other places that shouldn’t be done or should be done differently. We don’t follow it that hurts people and the most important thing we can do is help people in the best way we can and to stay humble about the fact that trying hard and caring deeply isn’t enough. You have to use information effectively.

Saul Marquez: [00:29:19] Michael what book and what podcast would you recommend to the listeners. Obviously besides the maning medical excellence because that’s a good one.

Michael Millenson: [00:29:28] One of the book’s most influential me was recommended to me by Jack Lehnberg of Dartmouth who was one of the pioneers in practice variation and is called the silent world of Doctor and Patient by Jake Katz and Dr. Katz’s a psychiatrist who is a refugee from Nazi Germany who is actually active as an ethicist in overseeing what happened with some of the Tuskegee trials and things like that. Who wrote this book. Doctor patient relationship in the 1980s which is absolutely wonderful. Conceptually it will challenge you and will cause you to look at the doctor patient relationship in new ways and you’ll go back to it again and again.

Saul Marquez: [00:30:09] What a great recommendation. And how about a podcast. Michael. I would recommend that listeners.

Michael Millenson: [00:30:13] I listened to WAIT WAIT DON’T TELL ME which is a way to stay up on current events and laugh while doing it. One of the things that never ceases to amaze me is even though I’m a news junkie and I look at all the different newspapers the news feeds and everything. Inevitably if I’m listening to a podcast like Wait Wait Don’t Tell me or watch the Late Show with Stephen Colbert or watching The Daily Show with Trevor Noah. Inevitably I find out about something. I didn’t know what happened. And so what better way to stay up on the news and to laugh while doing it.

Saul Marquez: [00:30:45] I love it. You got to stay lighthearted while you’re in your pursuits to drive excellence. Michael really appreciate that listeners. If you’re driving or going for your jog just don’t worry about jotting this down. Just go to outcomesrocket.health/millenson that’s M I L L E N S O N in Michael Millenson and you’re going to be able to find all the show notes as well as the books and projects that Michael’s working on there at your fingertips. Michael before we conclude I love if you could just share a closing thought and then the best place for the listeners could get in touch with you or follow you.

Michael Millenson: [00:31:22] Well I’m on Twitter and @mlmillenson a little innocent man. And of course on on linked in my email address is on my site. www.millenson.com or healthpolyvinyl.com. And I think that this is one of the best times to be in health care ever other than the invention of antibiotics which of course is a medical breakthrough. And in health care delivery the advent of health insurance after World War II. This is the most transformative time ever in healthcare and it is a transformation that is making here better safer more patient centered more inclusive. So I think that all of your listeners who are in health care should cherish this as an opportunity as a career opportunity as a personal opportunity to really make a positive difference.

Saul Marquez: [00:32:15] Michael. I love it. What a great closing thought. And listeners take that as an action item for yourself. We are in one of the greatest eras in health. And take Michael’s encouragement and my own to take advantage of it and make it even better with your contributions and so Michael just a big thank you from me and from all of our listeners for carving out some time in your busy schedule. Really appreciate you being on the podcast.

Michael Millenson: [00:32:41] My pleasure thank you Saul.

: [00:32:46] Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.health for the show notes, resources, inspiration and so much more.

Recommended Book/s:

Demanding Medical Excellence

The Silent World of Doctor and Patient

Wait wait don’t tell me

The Best Way To Contact Michael:

@MLmillenson

Michael Millenson

Mentioned Link/s:

http://millenson.com/

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