Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday December 5 at 1pm PST 4pm EST are patient safety expert Michael Millenson, patient advocate & entrepreneur Robin Farmanfarmaian; futurist Jeff Goldsmith; and employer & care consultant Brian Klepper.
You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
By MICHAEL MILLENSON
Open enrollment season for Medicare, which began Oct. 15 and ends Dec. 7, triggers a deluge of information about various options. Since I’m a health care consultant and researcher as well as a Medicare beneficiary, I’ve looked critically at what we’re told and what we’re not. Unfortunately, information crucial both for the individual and for the broader policy goal of moving toward a “value-based” care system is often difficult to find or not available at all.
The most glaring example involves Medicare Advantage, the increasingly popular insurer-run plans that are an alternative to traditional fee-for-service Medicare. Plans receive a quality grade from one to five stars from the Centers for Medicare & Medicaid Services. Those grades are designed to incentivize providing the highest quality care for the money — the very definition of “value.” A high grade triggers both a boost in payment from Medicare and a boost in enrollment. Not surprisingly, almost three-quarters of people chose a plan with a 4-, 4.5- or 5-star rating, according to CMS.
Those ratings, however, should come with a large asterisk attached. It’s not just that the methodology can be controversial, particularly when a lower grade is meted out. It’s that the star ratings aren’t anchored in geography, as one would naturally expect; i.e., the rating is for the plan offered in my area. What is colloquially called a “five-star plan” is actually a plan that’s part of a five-star Medicare contract — and those two typically are not the same thing.
For instance, one large insurer contract that I tracked included at least 17 plans scattered across the country. It defies common sense to believe that care quality is identical among plans in, say, Rhode Island, Mississippi, Illinois, Colorado, and California just because they all share the same government contract number.
If you’re wondering who benefits from this not-very-transparent transparency, some insurers have been known to improve the rating of a low-performing plan with a small number of members by merging it into a contract with more members and a higher rating.
In 2024, nearly 33 million people, or 54% of Medicare beneficiaries, were enrolled in an MA plan, according to KFF (formerly the Kaiser Family Foundation). KFF expects that number to increase to nearly 36 million in 2025. It’s a long-accepted truism that “All health care is local.” Medicare beneficiaries deserve local plan information.
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Joining Matthew Holt (@boltyboy) on #THCBGang on Friday November 8 are THCB regular writer and ponderer of odd juxtapositions Kim Bellard (@kimbbellard); Principal of Worksite Health Advisors Brian Klepper (@bklepper1); patient safety expert and all around wit Michael Millenson (@mlmillenson); and digital health investment banker Steven Wardell (@StevenWardell). There may well be a discussion about an election.
You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
By MICHAEL MILLENSON
This article is adapted from a talk given Sept. 7 at the 11th Annual World Patient Safety, Science & Technology Summit in Irvine, California, sponsored by the Patient Safety Movement Foundation. World Patient Safety Day is Sept. 17, with a series of events in Washington, D.C. from Sept. 15-17 sponsored by Patients for Patient Safety (US). An agenda and registration, which is free, can be found here.
Since I started researching and writing about patient safety, one question has continually haunted me: given the grievous toll of death and injury from preventable medical harm that has been documented in the medical literature for at least 50 years, why have so many good and caring people – friends, family, colleagues – done so little to stop it?
To frame that question with brutal candor: Why do we still kill patients? And how do we change that? The answer, I believe, lies in addressing three key factors: Invisibility, inertia and income.”
When it comes to invisibility, we’ve all heard innumerable times the analogy with airline safety; i.e., plane crashes occur in public view, but the toll taken by medical error occurs in private. That’s true and important, but there are other factors that promote invisibility that we in the patient safety movement need to address.
For instance, while I’m not a physician, I can say with certainty that every patient harmed in the hospital had a diagnosis (right or wrong), and often more than one. Yet disease groups such as the American Heart Association and American Cancer Society have been uninvolved in efforts to eliminate the preventable harm that’s afflicting their presumed constituents.
Why have we let these influential groups sit on the sidelines rather than make them integral partners in raising public and policy visibility? For instance, there are a number of Congressional caucuses – bipartisan groups of legislators – focusing on cancer. While much attention is paid to the Biden administration’s cancer moonshot, what about the safety of cancer patients treated today, while we wait for an elusive cure?
In a similar vein about missed opportunities for visibility, the stories told by patient advocates about the harm a loved one has suffered are always powerful. However, the specific hospital where the harm took place is typically not mentioned, perhaps for legal reasons, perhaps because it’s become a habit. The effect, however, is to dilute the visibility of the danger. The public is not confronted with the uncomfortable reality that my reputable hospital and doctor in a nice, middle-class area could cause me the same awful harm.
Finally, one time-tested way to hide a problem is to use obscure language to describe it. Back in 1978, RAND Corporation published a paper provocatively entitled, “Iatrogenesis: Just What the Doctor Ordered.” It concluded: “In terms of volume alone, we are awash in iatrogenesis.”
That would have been a compelling soundbite decades before the 1999 To Err is Human report if everyone in America studied ancient Greek. “Iatrogenesis” is a Greek term meaning “the production of disease by the manner, diagnosis or treatment of a physician.” In short, patient harm is “what the doctor ordered.” Although there was plain English in the paper, the technical focus allowed the stunning prevalence of patient harm to remain publicly invisible.
Of course, today we don’t need to use a foreign language to hide unpleasantness. We can use jargon and euphemism. We have “healthcare-acquired conditions” and “healthcare-associated infections.” At least the Greek term acknowledged causality and responsibility.
The invisibility of the scope and causes of patient harm leads inevitably to inertia and complacency.
Continue reading…By MICHAEL MILLENSON
It’s close to an iron rule: Politics drives policy. In that context, the health policy issues that were largely invisible at the Republican and Democratic conventions taught a crucial political lesson.
Start with access. According to KFF (formerly the Kaiser Family Foundation), more than 25 million Americans have been disenrolled from Medicaid as of Aug. 23. Ten states, all dominated by Republican legislatures and/or governors, have declined to expand the program, leaving 2.8 million Americans unnecessarily uninsured.
Yet if you were looking to either convention to find protestors telling heart-rending personal stories to humanize those statistics, you’d search in vain. There were none.
The Poor People’s Army, a group advocating for economic justice, did invite reporters covering both conventions to focus on one of the most urgent issues facing the poor and near-poor – not medical care access, but the lack of basic housing.
Homelessness set a record in 2023, according to the National Alliance to End Homelessness, affecting one in 500 Americans, while the number of renters forced to pay more than 50 percent of their income has surged since 2015. The former is apparent on the streets of every big city, while the latter is felt by millions in every paycheck.
The political lesson is clear. While support for Medicaid expansion was buried deep in the Democratic platform, at the grassroots level there’s no sign of the kind of passionate involvement that could drive votes in a close election. Medicare, of course, is a separate issue, with both parties promising to protect the program dear to the hearts of the nation’s elderly, who have the highest percentage voting turnout of any age group.
Of course, even those with good health insurance often have to worry about medical costs, with KFF polling finding that a shocking 41% of U.S. adults have medical debt. However, although the phrase, “It’s the prices, stupid!” has become a bipartisan policy refrain, there are no swing state votes to be swung by harping on the alleged cupidity of the local hospital. So while denouncing “medical debt,” no one did.
On the other hand, Democrats spoke repeatedly about the depredations of “Big Pharma.” The GOP platform satisfied itself with a vague promise to “expand access to new…prescription drug options” to address prescription drug costs that “are out of control.” The responsibility for those prices was unspecified.
As for health insurers, articles about questionable denials of medical claims by giant insurers like United Healthcare and Humana have garnered headlines and expressions of outrage. Once again, however, the grassroots reaction is the key. There has been no outpouring of public indignation remotely comparable to the HMO backlash of the 1990s. As a result, health insurers have largely vacated the role of politically visible corporate villain.
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By MICHAEL MILLENSON
“A reform,” wrote a 19th-century British parliamentarian, “is a correction of abuses. A revolution is a transfer of power.”
As we celebrate the American Revolution, catalyzed by men who broke ranks with their peers to overthrow a power structure that seemed immutable, let’s also celebrate those physicians who broke with their peers and declared independence for American patients.
The British Empire believed it was exercising “benign colonialism.” Physicians, similarly, traditionally believed “that patients are only in need of caring custody,” observed psychiatrist Jay Katz in his 1984 book, The Silent World of Doctor and Patient. As a result, doctors thought it their moral duty to act as “rational agents” on the patient’s behalf.
The first spark to set that notion on fire came immediately after World War II with the publication of a book, The Common Sense Book of Baby and Child Care, that became a surprise best-seller. Dr. Benjamin McLane Spock, author and pediatrician, told parents that their common sense was often as reliable a guide as any doctor’s advice.
At the time, the American Medical Association’s Code of Medical Ethics advised physicians that “reasonable indulgence should be granted to the caprices of the sick.” Even though new moms were not ill, many pediatricians nonetheless deemed it entirely unreasonable for them to decide when to feed their babies. Instead, the doctors gave them given feeding schedules.
Spock, in contrast, reassured moms that centuries of human history showed they could decide for themselves when to feed their infant, doing so “when he seems hungry, irrespective of the hour.”
As I wrote in a history of participatory medicine, as those babies grew into adulthood, they “would use legal, economic and political pressure to undermine a medical culture that genuinely believed sharing too much information could be harmful.”
Along that journey, however, patients would acquire crucial help from doctors with the imagination and courage to think and to act outside the existing paradigm.
It wasn’t a quick process. As with the American Revolution, the abuses had to accumulate and resistance had to build. In 1970, a group of Boston feminists frustrated by a system that told them to listen to their doctor and not ask questions published a booklet entitled Women and Their Bodies. One year later, a court decision resulting from a malpractice case required physicians for the first time to specifically disclose the full risks of a procedure in language the patient could understand. A year after that, in 1973, what had become the Boston Women’s Health Collective published Our Bodies, Ourselves. The book has sold millions of copies.
Also in 1973, the American Hospital Association, facing the threat of Congressional action, adopted a “patient bill of rights” that contained such guarantees as patients having the right to know the names of all the physicians treating them!
Meanwhile, a handful of doctors started chipping away at the medical pedestal, with research uncovering common abuses of power like unnecessary tonsillectomies and hysterectomies. John Wennberg, working with colleagues who deployed nascent computer capabilities, demonstrated enormous variation in even the everyday practice of doctors in the same area seeing the same kind of patients. The “caprices” of judgment, it seemed, were not just a patient problem.
Peer-reviewed medical journals rejected Wennberg’s first article. The university where he worked pushed him to find a different employer. Physician colleagues shunned him. But as policymakers’ concern over soaring medical costs grew, Wennberg’s work went mainstream.
“Inevitably, once you start down the variation path and ask which rate is right, you come up against who’s making the decision and whose preferences are being reflected,” Wennberg later said. “That’s where the revolutionary aspects of what we’re doing really are.”
Following that logic, Wennberg and a fellow physician, Albert G. Mulley, Jr. – who had experienced the impact of practice variation when trying to treat his severe back pain – in 1989 formed the Foundation for Informed Medical Decision Making. Its mission was to develop and disseminate video programs enabling patients to become partners in their care.
It was Wennberg who recommended Katz’s book to me, with its extraordinary statements about doctor “fantasies” of “authoritarian control” and its blunt accusation that doctor’s reluctance to involve patients in jointly thinking about care choices constitutes psychological “abandonment.”
Like Wennberg, Paul Ellwood, who’d coined the term “health maintenance organization,” also tried to put shared decision-making into practice. In 1988, he called for adoption of “a technology of patient experience.” In 1995, he founded the Foundation for Accountability (FACCT), with tools such as “CompareYourCare” to help patients play a more active role in medical decisions.
Meanwhile, Harvey Picker, a successful businessman who said he wanted the health care system to treat patients as persons, not as “imbeciles or inventory,” joined with the Commonwealth Fund to support a group of researchers who promised to promote what Tom Delbanco, the lead physician, called “patient-centered care.” The group’s 1993 book, Through the Patient’s Eyes, helped popularize the concept, which a 2001 report by Institute of Medicine formally designated as one of six aims for the health care system
It was Delbanco who with colleagues in the first decade of the 21st century founded the “open notes” movement to give patients the right to see the doctor’s notes that were still a hidden part of the electronic health record. That push eventually led to legislation and regulations giving patients full access to all their EHR information.
But, of course, by then there was another doctor the public was increasingly turning to: “Dr. Google,” also known as “the Internet.” In 1996, Dr. Tom Ferguson, who had been medical editor of the Whole Earth Catalog, wrote a book entitled, Health Online: How to Find Health information, Support Groups, and Self-Help Communities in Cyberspace. Three years after his death in 2006, a group of physicians and patients would found the Society for Participatory Medicine, following the principles of an individual CNN would call the “George Washington of the empowered patient movement.”
None of these physician revolutionaries acted in a vacuum. While all faced resistance, they also had support from colleagues, physicians and non-physicians alike. Eventually, they were reinforced by patient activism, public opinion, legal requirements and, at a glacial pace, changes in the culture of medicine. Those changes, in turn, came about because of the work of physicians like Donald Berwick, Paul Batalden, Leana Wen, Victor Montori, Danny Sands and many others.
Still, it is those physicians who over the years repeatedly acted to free patients from “authoritarian control” – even if their language was more diplomatic – that blazed the path.
Michael L. Millenson is president of Health Quality Advisors LLC, and author of the classic Demanding Medical Excellence. He can be reached at michael@healthqualityadvisors.
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday September 28 at 1pm PST 4pm EST are futurist Jeff Goldsmith: author & ponderer of odd juxtapositions Kim Bellard (@kimbbellard); and patient safety expert and all around wit Michael Millenson (@mlmillenson).
You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday August 31 at 1pm PST 4pm EST are the small but mighty pairing of Kim Bellard (@kimbbellard); and patient safety expert and all around wit Michael Millenson (@mlmillenson).
You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
This is the last of the classics that THCB will run to celebrate our 20th birthday. And we are finally tackling the most important of questions. Is what we call this thing one word or two? Back in 2012 Michael Millenson had the definitive answer–Matthew Holt
By MICHAEL L. MILLENSON
A recent contributor to this blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.
The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.
Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medical care driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”
Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.
The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”
A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.
Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.
So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.
When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.
At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.
The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.
However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AHCPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”
Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.
Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.
I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.
Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday August 17 at 1pm PST 4pm EST are futurist Jeff Goldsmith: medical historian Mike Magee (@drmikemagee); policy expert consultant/author Rosemarie Day (@Rosemarie_Day1); and patient safety expert and all around wit Michael Millenson (@mlmillenson);
You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
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