A Conversation with Dr. Richard Isaacs, CEO of The Permanente Medical Group and the Mid Atlantic Permanente Medical Group
By AJAY KOHLI, MD
Organizations aren’t built in crises. Their mettle, their history and their leadership define how organizations adapt and succeed, particularly in difficult times. Of the three, the most important quality is leadership. In this regard, Kaiser Permanente is leading the way in healthcare delivery.
had the opportunity to speak with Dr. Richard Isaacs, CEO of The Permanente Medical Group and The MidAtlantic Permanente
Medical Group, to discuss the strategic vision and granular details of
Kaiser Permanente’s response to the global pandemic of COVID-19.
Kaiser Permanente has a strong foundation in the history of delivering care to the vulnerable. Founded in 1945 by a surgeon, Dr. Sidney Garfield, and an industrialist, Henry J. Kaiser, the organization grew from a single hospital in Oakland, California into one of the largest physician-led organizations in the world. Currently, it boasts more than 22,000 physicians responsible for the care of more than 12.5 million lives.
Many question how large healthcare organizations, like Kaiser Permanente, can adapt to a rapidly evolving problem, like the global pandemic of COVID-19, especially when cities and even countries are struggling under the burden.
Today on THCB Spotlights, Matthew speaks with Jeremy Orr, CEO of Medial EarlySign. Medial EarlySign does complex algorithmic detection of elevated risk trajectories for high-burden serious diseases, and the progression towards chronic diseases such as diabetes. Tune in to hear more about this AI/ML company that has been working on their algorithms since before many had even heard about machine learning, what they’ve been doing with Kaiser Permanente and Geisinger, and where they are going next.
Filmed at the HLTH Conference in Las Vegas, October 2019.
Today on Health in 2 Point 00, Jess is in Italy…and has me up far too early in the morning for this episode. On Episode 79, Jess asks me for an update on uBiome after their raid by the FBI. We also talk about nutrition startup Noom’s $58 million raise and clinician house-call platform DispatchHealth’s $33 million raise. In other news, Kaiser Permanente is launching a network to integrate the social determinants of health with their EHR. –Matthew Holt
When it comes to health care prices, the burden piled on payers can seem almost cartoonishly heavy. News stories on the state of the industry read as though some satirist decided to exaggerate real systemic flaws into cost-prohibitive fiction. A particularly painful example hit the presses earlier this year, when a writer for Reuters revealed that the cost of a full course of oncology treatment skyrocketed from $30,447 in 2006 to $161,141 in the last few years. The change was so unbelievable as to verge on dark comedy — but there isn’t much to find funny in the situation when lives and health outcomes are on the line.
For the average employee in my home of Silicon Valley, the price crunch is challenging regardless the size of your paycheck. For local employers, however, the dilemma can be even more pointed. Today, employees of companies, large and small, expect their employer to provide comprehensive health care benefits and are largely unaware of or insensitive to the factors exacerbating market problems today. Providing these benefits, however, is easier said than done.
Employers and insurers alike face a multitude of barriers to connecting employees with affordable care. Recent research suggests that prices will increase at an average clip of 5.8% annually between now and 2024, well above the expected rate of inflation. Even worse, the increased consolidation of healthcare providers has drastically undermined the negotiating power that payers would otherwise have in more competitive markets. In Northern California, for example, major health systems, including Sutter Health, sparked outrage and protest as they have managed to amass enough of the region’s hospitals, outpatient facilities, and primary care offices to diminish regional competitors and set what many view as unacceptably high rates — all the while knowing that the lack of local competition makes it challenging for the major health insurers to push back.
Today’s health care providers face the formidable challenge of delivering better, more affordable and more convenient care in the face of spiraling care costs and an epidemic of chronic disease. But the most innovative among them are making encouraging progress by “integrating”—which in this context means working across traditional boundaries between patients and clinicians, health care specialties, care sites and sectors.
The impulse to do so is shrewd, according to our innovation research in sectors from computer manufacturing to education. We’ve found that when a product isn’t yet good enough to address the needs of a particular customer segment, a company must control the entire product design and production process in order to improve it. This is necessary because in a “not-good-enough” product, unpredictable and complex interdependencies exist between components, so each component’s design depends on that of all the others.
Given this, managers responsible for the individual components must collaborate—or integrate—in order to align components’ design and assembly toward optimal performance. IBM employed an integrated strategy to improve performance of its early mainframe computers, and this enabled the firm to dominate the early computer industry when mainframes weren’t yet meeting customers’ needs.
In health care delivery, such integration is analogous to, but something more than, coordinated care. It means assembling and aligning resources and processes to deliver the right care, in the right place, at the right time. This type of integration is a core aspiration of innovative providers leading hot-spotting and aging-in-place programs, capitated primary care practices, initiatives addressing health-related social needs, and other care models that depart from America’s traditional, episodic, acute-care model. How are they tackling it? They’re leveraging very specific tools to facilitate work across boundaries. Here are six of the most common we uncovered in our research:
I am writing this letter because for two months I tried to get ahold of Darryn Carter, a case manager at your company who was assigned to process a complaint I filed about care I received that I feel was harmful and irresponsible.
The legal and rational reason for this current writing is this: the letter I received from Darryn Carter rejecting my complaint claim stated that I have a legal right to see the documentation and evidence used to make the decision about my case. I would like to see that evidence file, and I have not been able to get in touch with Mr./ Ms. Carter or anyone else at Kaiser to send the file.
The emotional and human reason I want to talk with Darryn Carter–and I think it’s appropriate to share this reason too, given that you are a care provider–is that I believe I received bad care at Kaiser, and yet no one at Kaiser has ever listened to what I have to say about it, despite months of my trying to tell someone. My concern and frustration, which is so strong that it drove me to spend a Saturday writing this letter, is not primarily about the bad care I believe I received but rather the wholehearted dismissal that your organization has levied through an unnavigable bureaucracy. This dismissal has kept me up nights, sometimes crying, sometimes fuming, sometimes brooding, always feeling that special type of indignity reserved for a patient with a care provider who blatantly and systematically refuses to care.
Recently, a jury awarded a young California resident $28.2 million for a delayed diagnosis of a pelvic tumor. The jury found Kaiser Permanente (KP) negligent. Doctors in the system, touted to be one of the finest systems by the President, allegedly refused an immediate MRI for back pain in a 17 year old. The patient eventually received an MRI three months after presentation, which found a tumor so extensive that the patient needed an amputation.
The case is instructive at multiple levels. It shows a tense dialectic between the individual and society. It also highlights a truism that many don’t understand or don’t acknowledge – missed/ delayed diagnosis and waste are reciprocal. They’re birds of a feather. You can’t have less of one without more of the other.
The patient presented with back pain. MRI for back pain is the poster child of waste. Why so? Because so many are negative. Even more are meaninglessly positive –disc bulges which simply mean “I’m Homo sapiens and I wasn’t intelligently designed to be sitting at the desk.”
High quality doctors don’t order MRI for back pain immediately, reflexively and incontinently. Think about this. A high quality doctor should say “I don’t think you need an MRI because it won’t change the management and doesn’t improve outcomes.” That’s the resounding message from the top. If it doesn’t improve outcomes it’s not a worthy test. High quality doctors will, once in a while, cost their organization a lot of money.
But quality is still not settled. Quality doctors must satisfy patients. If a patient asks for an MRI for back pain the quality doctor must acquiesce, if that refusal dissatisfies. I’m confused. Ordering an MRI for back pain is poor care. But not ordering an MRI for back pain is poor care. Which is it?
We don’t know the facts of the case. It’s possible that the patient had a neurological deficit that should have raised the urgency. It’s possible that the physician didn’t examine the patient and had he/ she examined, the tumor might have been detected. We don’t know. We shouldn’t judge (1).Continue reading…
In the past, the AMA published an article questioning the merits of patient portals — the primary tool for engaging patients. Rob Tennant, senior policy adviser with the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Association and the American College of Medical Practice Executives raised the fundamental issue: “The business case just hasn’t been made.” I’ll attempt to make it.
Perhaps the best evidence of the business case is when industry visionaries/organizations/leaders such as HIMSS (the professional association for healthIT), Aetna and Kaiser Permanente have made significant investments in patient engagement.
I’ve excerpted a couple sections of Pam Dolan’s article on the topic to set context and then I will address the business case. The patient portal benefits assume that it’s more than a simplistic silo’ed patient portal tethered to an EHR since they are broadly available. [Disclosure: My company, Avado, is one many patient engagement companies.]
This is why I would call it the patient portal & relationship management system or simply patient relationship management system to distinguish it from traditional limited patient portals.
Physicians are understandably concerned about being overwhelmed by emails if they provide an option for secure messaging. As healthcare transforms, financial incentives have a big effect on the willingness to take on what many perceive to be “more unpaid work” (forgetting the fact that playing voicemail tag is also unpaid and frustratingly inefficient). Interestingly, the physicians who have given out their phone number or enabled secure email (without remuneration) haven’t found they are overwhelmed by any means. In the case of the groundbreaking Open Notes study, many of the doctors just heard crickets.
Technology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.
In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.
This humorous equation speaks volumes about technology and health care:
NT + OO = COO
New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.
For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?
Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?
Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?
When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.
Hospitals and physician groups throughout the country are installing and working with electronic health records at a rapid pace. Some organizations integrate the systems beautifully, others do not.