Physicians

HEALTH PLANS/PHYSICIANS/TECH:Health care, the way it should be (or How to stop worrying and learn to love the bomb), by Pat Salber

Pat Salber writes The Doctor Weighs In. She is a doc, an ex-med director at California blue shield, and a Kaiser Permanente member. And she loves them. This is why, and it’s quite an advertorial for Kaiser and an indictment of how everyone else does it. So if this becomes the standard, and people find out about it (and with $80m of advertising budget a year behind it, they will find out) can the rest of the US system compete?

Health care, the way it should be or  (How to stop worrying and learn to love the bomb)

By PAT SALBER

I have to tell you again about what great health care I get from Kaiser Permanente Northern Cal. Drhealth (Yeah, I know, they screwed up on the transplant service).  But, they are doing a lot of the things we, the wonks, have been hollering about for years.  Read this.

Sunday night I noticed new “floaters” in the right visual field of my right eye.  They were different from the run of the mill floaters – those little dark circles — most of us have.  These were like long lines and they only moved on the right side of the visual field.  The next day, I started having sparkling lights, again in the right visual field.  Now, even an emergency physician knows this could indicate a retinal detachment (serious indeed).  So mid-afternoon, when I had convinced myself it would be stupid to miss my own diagnosis, I called KP.  The woman on the phone in the opthalmology department clearly had been trained.  When I talked about the sparkles, she put me on hold and got a nurse. 

The nurse tried her best to get me in the same day.  She had an appointment available, but being rush hour, there was no way I could make it. She carefully went over the symptoms of retinal detachment and compared them to what I was experiencing.  Together we decided it was OK to wait until the next am for an appointment.  She carefully explained that if certain symptoms occurred (e.g., a sensation of a curtain coming down over the eye), that I needed to go to the emergency department right away as that could indicate a retinal detachment.

The next day (today) I showed up at the opthalmology department.  The receipt I was given for my $15 co-pay listed the dates I had had all of my age/gender specific  preventive services and the dates the next ones were due.

There was no wait to see the doctor.  I was put in an eye exam room and saw a nurse right away.  She explained everything she was going to do.  She anesthetized my corneas,  she tested my vision (with glasses and with pinholes), she used the slit lamp to look at the corneal surface, and then she put in drops to dilate my eyes.

After about 15 minutes (waiting for the eyes to dilate), Dr. Prusiner, chief of the department came in to see me (he is the brother of Stan Prusiner, the Nobel Prize winner who discovered prions).  He did a very thorough exam of both retinas using a variety of techniques.  He explained that I had a vitreous detachment (annoying, but otherwise, no big deal).  He showed me a color picture of an eye with a vitreous detachment.  He answered all of my questions.  He did  not seem rushed (because the nurse had done a lot of the early work for him).

We were finished, he gave me a  4 x 6 piece of paper with his name, his photo and the URL of his home page.  Here’s the link  so you can see how nice it is.  This is, I think, the new KP Connect.  It also showed all of the stuff (by major categories) that he had on his home page.  He wrote down the diagnosis “vitreous detachment” on the paper and drew an arrow from it to name of the link where I would find the information he had chosen for his patients to read about this condition. He urged me to read it.  I went on the site, found the condition, and, lo and behold, everything he told me was what was on the site.

He then told me, in detail, what symptoms would require me to call or go to the ER right away.  But he assured me that the symptoms represented complications highly unlikely to occur.

By the way, he said as I was leaving.  Be sure to make an appointment with the optometrist.  I think we can improve the correction of your left eye.

I challenge you to find one single thing you would want that I didn’t get.  This is the way health care should be.

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27 replies »

  1. Kaiser is fantastic!!! …as long as you don’t actually need to go in and be seen for anything!

  2. If Kaise is so fantastic, why must patients sign an anti-suit waiver (along with their permission for treatment) upon entrance to the ER?
    Why do certain Kaiser physicians tell patients “I’m only allotted a certain number of MRI’s each year, and after that I’ll have to pay a premium out of my own paycheck?”
    Why won’t the Kaiser review board let patients seek care from outside surgeons who have ACTUALLY PERFORMED their intended procedure?
    Why, after a Kaiser surgery has been botched, does the review board change their tune and allow patients to be transferred to us for clean-up neurosurgery? After being operated on by a surgeon who, prior to the procedure, informed the patient “I’ve read about the surgery, but I’ve never performed it. You’ll be my first”?
    When a Kaiser patient comes another hospital ER, even at a county hospital, why will Kaiser only pay for basic stabilization and transport? Emergency surgery is not covered.
    People are dying. Not just the transplant patients. Pregnant mothers in pain who can’t get a diagnostic ultrasound in the ER for their unborn child, who later dies from umbilical cord strangulation. Elderly patients with a diagnosed tumor who can’t get an annual MRI, even though they have new visual loss.
    I work at a state hospital. I’ve seen what can happen. If you’re a patient at Kaiser, you need to have a serious look at yourself, and the healthcare team with which you’re associating. If you don’t, you’ll wind up dead.

  3. The doctors service should not change because he works for Kaiser. A doctor should provide the best service he can because he is in business and his business depends on customer service.

  4. Just for those of you who don’t know, the British Health Service has come out on at least two occasions to visit Kaiser leaders, looking for advice about how to better run their own health programs

  5. The reason health care costs are rising so rapidly is because of the high rate of uninsured, and the free care that hospitals and doctors have to provide. Someone has to cover the costs, and that comes out of the pockets of those that have insurance, that is private insurance as well as Medicare and Medicade, or from those who can pay for medical care on their own.
    And the reason there is so much corruption in the medicaid and medicare arenas, is because every year reimbursements go down from the government, and fraud or running unnecessary tests etc. is the only way some doctors can make ends meet.
    Just my opinion!

  6. First, regarding Medicare and Medicaid– yes, their costs are increasing faster than inflation–but not as fast as the cost of health care in the private sector.
    Going back to Kaiser, when compared to other health plans, patient satisifaction is high: in regions of the country where Kaiser is well-established, the annnual voluntary turnover rate (the rate at which members leave the program when given the opportunity each year) is less than 3 percent.
    When I was writing “Money-Driven Medicine,” Dr. Jack Mahoney, director of health care benefits at Pitney Bowes told me: “People are incredibly loyal to Kaiser. We couldn’t operate in Northern California without offering it–people wouldn’t come to work for us. We rate HMOs for quality, and Kaiser is always the benchmark.” (Hahoney is an M.D. –he was Gerry Ford’s physician when Ford was in the White House and he runs an excellent health benefits program.
    Finally, as for Kaiser’s use of IT– the system has already begun to pay off. Due largely to Kaiser’s IT-supported approaches, by 2004 heart disease was no longer the number one cause of eath among Kaiser Permanente’s memebers in Northern California–although it remained so for the California population at large.

  7. Jason,
    I remain a skeptic regardiing socialized medicine. I note that Medicare and Medicaid continue to increase in cost significantly faster than the sum of inflation and (eligible) population growth while fraud is a serious issue in both programs.
    I also note that many large employers self-insure and contract with insurers for administrative services only or so-called ASO contracts. Perhaps one of the brokers on the blog could provide some insight into how much administrative services cost per member per month on average and what that comes to as a percentage of the client’s total dollars spent on employee healthcare.
    I think there is plenty of opportunity for administrative savings if insurers simplified their offerings and paid a given provider the same price for the same service no matter which of their products the individual insured has. They could then compete on deductibles, co-pays, scope of coverage and customer service.
    I also never hear much about the meaningful differences that likely exist between the U.S. and countries with national health insurance regarding how they deal with futile care at the end of life. The UK uses QALY metrics, but I don’t know how the other countries deal with it. I personally support QALY metrics, but many others tell me it would never fly in the U.S., at least not yet. I suspect there is a lot of money to be saved here especially if we could signficantly drive up the percentage of the population (especially among the elderly) that have executed living wills and advance directives.
    Finally, we still need to make a lot of progress in the area of pricing transparency, especially for hospital charges, perhaps coupled with unbiased, objectives infomediaries to help patients evaluate the risks, benefits and cost-effectiveness of various treatment options.
    The bottom line, in my opinion, is that a healthcare system that preserves an important role for the private sector is a much better fit with our national culture than a one size fits all government system.

  8. Barry,
    I would bet it compares favorably to America at large, but would compare very UNFAVORABLY with socialized medical nations in Canada and Europe from a cost standpoint.
    Those systems operate without any middle man like Kaiser skimming money off the top.
    I think the fed govt should take some of KP’s practices like EMR and build a socialized medical model that eliminates all the middle man insurance companies, just like Europe operates.
    Of course, KP and the rest of the insurance industry would go out of business overnight, so they would fight it severely.
    The powerful insurance lobby is the only reason we dont have socialized medicine right now. They are the clear losers and are fighting tooth and nail in DC to keep it from happening.

  9. Since Kaiser has over 8 million members (greater than the population of some countries with national health insurance), I wonder if it has made any data available regarding average life expectancy, inpatient hospital days per 1,000 members, etc. and how their stats compare to the U.S. population at large. Has electronic medical records and evidence based medicine reduced costs and medical errors? How does their malpractice payout experience compare to non-Kaiser doctors within a given specialty? There should be a lot of useful data to be mined here.

  10. I think that when you compare the private practice model to the Kaiser model, Kaiser is doing it right. The provide evidence-based healthcare that’s integrated. Nobody else can provide that. In addition, Kaiser has and is well ahead of the competition in its IT systems–they have a functioning emr and an amazing patient driven web site that allows patients to email their doctor, check lab results and book appointments online. Prevention of disease is their goal and doctors get to focus on this instead of insurance reimbursements or enticements by pharma to prescribe their latest, most expensive drugs (KP Norther Cal has a strict no pharma rep policy at all offices)

  11. Some of you folks don’t seem to get it. This is about how medicine should be practiced, not premiums and lost laptops. KP physicians work in a system that allows them to focus on medicine. Not business, not paperwork for reimbursement, not staffing, not malpractice insurance, or any number of other distractions that every other onesy-twosy doctor (aka “independent business person/entrepeneur”) has to worry about. Kaiser has a system designed around allowing physicians to practice medicine. They have the systems and supports to allow them to focus on providing good care. Not to mention support for CME, quality initiatives, a wide variety of support staff and excellent connectivity through their information systems.
    They get bad press because of their size and some of their ancient history. If solo doctor A screws up, his patient says “Doctor A sucks”, but if a Kaiser physician screws up, its “Kaiser sucks”. I have been a Kaiser patient in the past and now because of a move have been forced to deal with the maze of insurance, physicians, “networks”, and the fragmentation in the system that typically exists. I would go back to Kaiser in an instant if it was available.
    One thing constant with any setting for healthcare is that you have to take control of your own medical situation. Too many people abdicate and that can get you in trouble in Kaiser just as easy as any other type of practice.
    Kaiser is not perfect, but I would choose a doctor who is a full-time physician working in a large multi-specialty group practice any day over a doctor who is a small business owner.

  12. Kaiser may be trying to PR-bury this, as well:
    http://sanfrancisco.bizjournals.com/sanfrancisco/stories/2006/07/24/daily47.html
    What makes me raise my eyebrows about health care professionals who preface their praise with “I don’t work for Kaiser, but I love them…” is that they are speaking from a position where they want to keep their options open in the future. Kaiser is a very comfortable professional destination for people at the top.
    In speaking of professional parachutes, does anyone know where David Brailer landed?

  13. One additional note for Laura: the issue isn’t that Kaiser makes mistakes. Everyone makes mistakes. The issue is Kaiser has a history of trying to cover up their mistakes, and seems to be determined with all the power of a thousand lawyers and “issues management consultants” to never, ever, ever make things right. They just wait for memories to fade. Therefore the consequences of Kaiser’s mistakes just go on and on and on.

  14. Just some history kids…
    The health plan and hospitals are owned by the Kaiser Foundation Health Plan. The Doctors are a private for-profit corporation called the Permanente Medical Group.
    BUT they have an exclusive contract with the Kaiser Foundation Health Plan and dont get patients from anywhere else. (As Laura says that’s not the case in a few markets where they basically are like any other health plan contracting with community doc IPAs)
    The organizaton was set up that way to get around California’s corporate practice of medicine laws (which in turn were set up to prevent corporations setting up in heatlh care and driving the solo docs out of busines, as happened in retail et al)
    However, note that there has been much controversy about whether the profits of the plan that are passed onto the docs–which do end up in the end in the doctors pockets–are motivating factors to the doctors to practice in the way that tadvantages the plan (i.e. do less rather than more).
    My sense is that the KP docs are well insulated from the financial impact of their clinical decsions on their own wallets (something that is NOT the case in the rest of physician practice), so I like it as a system–especually as the plan keeps its patients for a long time and therefore has an interest in keeping them healthy. But there are plenty who disagree with me.
    Finally, it’s a huge organization and has more than its share of corporate politics. But this post from Pat shows that they clearly are doing lots right (as well as the stuff that’s in the news about how they’re screwing up!)

  15. First, I’m a former KP employee, from the company’s national offices. to clear up confusion; in some places, a few regions, KP has to contract with local docs who are not in one of the Permanente Medical Groups. In CA, OR, HI, and most of the larger regions, that’s not the case, but in GA, Mid-Atlantic, Cleveland and Colorado Springs it is.
    I want to echo Pat’s comments. When I left KP, the new employer didn’t offer Kaiser as an option for insurance–but I did not want to lose the kind of care and service Pat’s talking about and got onto my hubby’s policy through his employer.
    The negatives stories that reach the press are amplified because of KP’s size. When you have eight million patients and 12,000 doctors, what are the odds that every once in a while something isn’t going to go right? That a really bad error will happen? If a doctor is in private practice, you won’t hear about his/her mistakes. Even a lawsuit wouldn’t bring them much media attention, because no one can link them to a big bad HMO. When a physician who practices in a KP facility or with a Permanente Medical Group makes a mistake, it’s not just his or her mistake; it’s now associated with a large entity, so that action is associated with the big bad HMO rather than just with the doctor.
    Remember the IOM report? In every medical office, in every hospital, there are mistakes made. Most of them never make the news, especially if Doc Smith in Wauseon, Ohio, accidentally killed old Mrs. Jones. He’s not part of a big organization, and if he hushes it up it won’t even hit the local paper.
    But these things happen every day. You just hear about the Kaiser incidents because of its enormity, and because of the scrutiny on an enormous organization that’s still fighting the old HMO backlash and its own early refusal to respond to allegations. (Back in the 70s, 80s KP rarely talked to the press. That makes for bad press relations and reporters have long memories.)

  16. “They spun of their physician network into an IPA” (Independent Physician Association???).

    You mean the doctors no longer work directly for Kaiser?
    I have also found Kaiser provides the best care in the area. Not only that, but Kaiser is the one organization, that won’t cut off your insurance if you become unemployed.
    You can continue to purchase the same plan you had, or can switch to a variety of other plans without a physical, as long as you have been a member of Kaiser.
    What other health insurer in the country would do that?

  17. I’ve always been a fan of the Kaiser model of care since (until recently) they very elegantly addressed a number of agency issues becuase of their non-profit organization. In addition, they seemd to symbolize the trade-off inherent in managed competition like frameworks where one could join a closed system at a lower insurance premium with known quality. Alas, the quality problems they have encountered seem all to have occurred after they spun off their physician network into an IPA that contracts with KP.

  18. So Peter — Dr. Salber talks about quality of care, and you ask about price and her compensation arrangements which are IMNSHO none of your cotton’ pickin’ business.
    Why?
    t

  19. On a recent conference call, a consultant from Hewitt Associates based in CA commented that Kaiser’s premiums used to be as much as 20%-25% below the competition in the CA market. In the last year or two, he said the gap has shrunk to 10% or so. He didn’t say why.
    Separately, I recently met an owner of a construction company with 55 employees based in Lodi, CA who provides comprehensive health insurance for all of his employees. I specifically asked him if he used Kaiser. He said no because he didn’t care for its program — not enough flexibility, etc.
    No system is perfect and no organization has all of the answers.

  20. I’d be interested to know what her monthly premiums are, how much of those premiums are paid by her employer, and what rate increases she has had over the last 5 years?(if she even sees the rate increases)

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