My NYT Room for Debate column: Should Kaiser Permanente be a national model?

My NYT Room for Debate column: Should Kaiser Permanente be a national model?

Kaiser Permanente is often hailed by health reformers as the model other health systems should replicate.

While integrated health systems have the potential to improve patient care, they also encourage hospitals to buy up physician practices to build their own Kaiser Permanente.  This increases provider clout in the marketplace, which has been shown to actually raise healthcare prices for patients:

Despite Kaiser Permanente’s stature as the model integrated health system, it hasn’t been able to substantially lower health costs. And rapid consolidation increases the clout of providers in the marketplace, allowing them to dictate prices. Worse, doctors in such consolidated settings have described pressure to bring in more money, “often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.”

Therein lies the tension that reformers face, as health reform encourages such provider consolidation by introducing the concept of accountable care organizations.

Read more about my opinion in today’s New York Times Room for Debate: Downsides for Doctors and Patients.

Enjoy the piece.

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  • Gisele

    I have to agree with the idea that these consolidated practices offer some advantages but have numerous potential hazards. I was in such a facility recently and it could have passed for a car dealership given the way it was positioned, run, and operated. 10-page financial documents to sign, payment consultants, standardized 10 minute visits with physicians spewing canned corporate expressions of value, etc. It reeked of being a turnstile or conveyor belt honestly and I suspect that such practices will become the norm and not the exception.

  • buzzkillerjsmith

    There is a good chance ACOs will drive up costs due to monopoly power unless the amount of money given to them to manage pts is capped. We been to this capitation dance before–pts and doctors hate it. On the other hand, pts and the government hate rapidly increasing HC costs. It is an open questions which they hate more.

    If physicians and other HC players have a financial incentive to provide less care, they will do so. I saw this at Kaiser every day from 1989 to 1995. Waiting lists, etc. etc. I’m not saying bad care, just less care. I suspect the outcomes were as good as those in private practice.

    Kaiser is a special case. The docs who work there are self-selected. Some docs, including me, hated it. Meetings and memos, memos and meetings. ACOs may give us the worst of both worlds: no costs savings, irritated docs (spent much time around a hospital administrator/business type lately), and unhappy pts. Time will tell.

    A better way: Have physicians run HC, not-for-profit, with some reasonable budgeting. Seems to work OK in a lot of other countries. But then where is the cut for the business types?

    • N N

      The last thing bureaucrats want are people knowledgeable about healthcare actually running healthcare. Just look at that old crank, Pete Stark, in his bid to destroy doctor-owned hospitals.

    • Homeless

      You mean those countries with socialized medicine?

      • N N

        Try actually RESEARCHING those countries with socialized medicine, rather than just thinking it’s a utopia based on left wing blogs. There is no such thing as a free lunch. Everything has a cost.

        • Homeless

          Which countries have non-profit, physician run HC systems?

          • southerndoc1

            Most of the Western European countries have systems based on small physician-owned practices, with an absence of for-profit corporations such as are taking over everything here.

          • buzzkillerjsmith

            Please see southerndoc below.

          • Homeless

            So your advocating for a socialist Europe model?

          • southerndoc1

            The European systems (with the exception of the UK) are absolutely not socialist, in that the government doesn’t own the means the production (i.e., the physician practices).

          • Homeless

            I thought it was ok to throw the word “socialist” around, especially since our president is a socialist and Obamacare is government takeover of health care.

            So you are advocating Medicare for All?

            Kaiser Permanente is non-profit with MD’s as executives and even on the Board of Directors.

            There is a large medical center in my area that is non-profit and is gobbling up small practices. One third of the Board of Trustees are physicians, including the Chair.

          • southerndoc1

            No, I’m advocating small, privately-owned practices that don’t have to support enormous administrative staffs, ridiculous executive salaries, and ever-increasing returns to shareholders.

          • Homeless

            Non-profits don’t have share holders.

            The loss of the small privately owned company has happened across many industries for quite some time. Perhaps Willie Nelson will do a benefit concert.

            Do you want the government to regulate how big a medical practice can be?

            My insurance plan is non-profit. I get my care from a for-profit clinic.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            When a certain size is reached, the only difference between non-profit empire building and for-profit share-holder pleasing is the amount of effort expanded on avoiding taxation.

            Government shouldn’t regulate size of medical practice unless monopoly issues arise, but government should also abstain from purposefully regulating small physician business out of existence.

          • southerndoc1

            Thank you.

          • Homeless

            So it’s not about a physician run non-profit healthcare system that doesn’t really exist in Europe but describes Kaiser…

            It’s about for-profit small medical practices without government funding?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Profit is what’s left after labor and overhead are paid. Physicians in small practice don’t have profits. They are paid for labor. Most of Europe and Canada too have small private practices paid mostly fee-for-service. It’s cheaper that way.

          • Homeless

            Not making a profit and being non-profit aren’t the same thing. None of the clinics in my area are non-profit except for the big medical centers.

            Most of Europe and Canada have governments that give doctors in small practices payment. I thought we in the US didn’t want a Medicare for All type system.

            My large non-profit health insurance company does this…but of course they are part of the non-profit empire.

          • buzzkillersmith

            Please see southerndoc below.

        • buzzkillersmith

          No need to shout.

  • karen3

    Kaiser Permanante is a great model for how to cherry pick only well insureds. If you have something seriously wrong, or a rare disease requiring specialized care, you are toast — you will die before you get your Kaiser doctor to admit that Kaiser can’t help you. Kaiser is NOT a good model

    • buzzkillerjsmith

      I recall a sad melanoma case from the early 90s. A lady had metastatic disease. The Kaiser oncologist told her that nothing could be done. Just die. He didn’t even set up a followup appt. He just had her come back to me. She and her husband pushed and pushed and finally Kaiser coughed up a referral to UCSF oncology. The pt died and almost certainly would have died anyway, but the Kaiser callousness certainly made an impression on me. Maybe it’s better now. I don’t really know.

      • http://twitter.com/davisliumd davisliumd

        It’s much different than when you were practicing from – 1989 to 1995. Here’s one story from a patient.

        http://thehealthcareblog.com/blog/2011/04/15/does-america-want-apple-or-android-for-health-care/

        • buzzkillerjsmith

          Email doc and doc “has to” respond it 48 hours. I love it. The Kaiser gulag for doctors. The more things change …

          Glad to hear things are better for pts. That is progress. But you can’t stuff 15 lbs of sugar into a 10 lb sack. That was the Kaiser way. Excuse me if I am still skeptical.

    • penguin50

      I’ve heard this before about Kaiser, but it hasn’t been my personal experience. I have an extremely rare cancer and Kaiser has offered me all possible treatments, including very new and wildly expensive procedures. I actually feel a little guilty about them spending so much on me even though I am a terminal case. And I never have to wonder if my Kaiser oncologist suggests a particular drug only because he gets a percentage of its cost, which can sometimes be a concern among those who see oncologists in private practice. My impression is that Kaiser doctors do labor under a great many onerous “rules,” but at least they don’t seem to have to personally fill out the endless paperwork that insurers, government agencies, and employers require. Those are all handled by Kaiser’s insurance department, which seems like a huge advantage for doctors.

      • karen3

        One sister of a friend dead from trying to get past the Kaiser rat race, one still working three years later on getting referrals for serious illness resulting in disabilty. It’s faux insurance as far as i am concerned.

      • buzzkillersmith

        Good point. As you well know, being sick is horrible, at Kaiser or not at Kaiser.

        I do not say that Kaiser gives bad care. It does not. If there were Kaiser in my area, I might join as a member.

        That said, I found Kaiser a hellish place to work. This was years ago. They say it’s better now. The question is this: Will enough physicians find it or similar organizations tolerable enough to work for? I myself don’t know. There has to be an overlap between what pts want and what doctors can stand.

        Another hypothesis that I can’t prove: The new ACOs, which have neither Kaiser’s culture or (high) ethical standards, will prove much poorer models. Time will tell.

        • penguin50

          It makes my heart sink to read of a doctor working under hellish conditions. Your work is difficult enough without having to deal with a burdensome corporate superstructure. It’s hard for a patient to really grasp what a doctor’s experience is like, although Kaiser’s rules-for-everyone-no-matter-what have sometimes been a source of frustration for me too. I mostly am treated by specialists now; they come into the exam room, sit down, and give me all the time in the world. They seem content. My PCP, however, needs to race to keep up with all the patients she is assigned to see. She still does a fantastic job—I am flabbergasted by how many issues she can competently address in fifteen minutes—but I don’t know how anyone could last under that sort of pressure. (But you might have different considerations in mind.)

          • buzzkillersmith

            Well put, p.

            Race to keep up, the hamster wheel. Med students (and I precept Univ of Washington med students) are simply appalled. I try to put a positive spin on it but philosophical conversations are few because of the hamster wheel.

            Primary care docs are stuck. I’m not competent to do much else. The checkers at Shopko impress me. I couldn’t do their job on my best dayt.

            The med students are not stuck (yet) and their eyes are wide open. The crystal ball is always cloudy but I predict a worsening primary care shortage.

      • S Sereb

        As a cancer survivor who has gone through less than you, I know from personal experience as a twenty plus year member that many terminal patients I’ve spoken to share the same story as you. I spoke with a terminal patient who was referred to MD Anderson by Kaiser. He spoke of the compassion and ease at which he was able to get that care.

    • S Sereb

      I do not what region you are located, but I have been a Kaiser member for over twenty years, and have had no issues with treatment of my “serious conditions”. In that course of time, I have had stage II cancer, and a couple of other serious conditions treated aggressively, and swiftly with treatments comparable to other health care systems in my part of the country. In fact, my Oncologist was open to new ideas I researched. He was new to Kaiser’s practice, having come from a private practice of many years, and shared that he was pleased to be allowed to practice medicine without interference from Kaiser. I have met others in the Kaiser system that feel like I do, too. I have been pleased to be treated by highly credentialed doctors’ (Johns’ Hopkins, etc.) in the best hospitals throughout my city. Kaiser is not perfect as I have had issues over the years, but so have others I’ve known with more traditional health insurance deleivery systems

  • N N

    If you actually look at the ACA bill, the goal of it was never to lower costs. The goal is more centralized control – hence why you have hospitals buying up practices, ACOs, bundled payments, etc.

    • buzzkillerjsmith

      They said they wanted to lower costs but that is bogus. Anyone with knowledge of HC ( of the world in general) realizes you can’t give insurance to 40 million or so more people and cut costs.

      Could not agree more about special interest sops. Health care is a whale, lots of meat to be eaten. The sharks are feasting.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        If you read the triple aim thing, you will note that it says “lower per-capita cost”. This is very careful phrasing. As you know I welcome the added cost for those 40 millions, and I would welcome the lower per-capita notion, if and only if, the “lowering” would occur from eliminating corporate gauging. Unfortunately it seems that there are other ways to lower “per-capita” costs, particularly for poor and not so savvy capitas.

        • buzzkillersmith

          I have not read it, but given your insightful and ethical posts, I believe you. Thanks for the education, Margalit. FWIW I too favor the expansion of HC.

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