The fee-for-service stand is supported by patients who are comfortably off and have health insurance almost as perfect as that of our politicians'. But the reality is our health care system is broken. We need change if we're going to care for our aging population.
This is the final part of a three-article series about gerontology, which author Eric Anderson, MD, wrote as a MetLife Fellow.
(Bias disclosure at end of article.)
Paul E. Bernstein’s self-assurance in treating any increase in Kaiser Permanente’s Medicare patients comes from his confidence in his group’s integrated efficiency.
Bernstein shows the confidence we all respect in our surgeons but also the resilience we have come to expect in any medical director who has had to fight Kaiser’s battle for acceptance amongst its peers for all those decades.
“We are focused on preventive care,” Bernstein, MD, says. “We have listed 64 measures to keep patients healthy if they are followed.”
Kaiser’s systems spotlight patients’ status at every visit, so when a patient visits an allergist, the provider can see if the patient is overdue on a mammogram and set one up.
“We’ve been practicing evidence-based medicine for many years,” he says. “We lead the nation in [gastrointestinal] cancer testing. We hold the Guinness World Record for colonoscopy screening.”
Michael J. Lalich, MD, clinical chief of the Family Practice department shows off the Wall of Guinness Book of Records.
It seems Bernstein is saying Kaiser has practiced efficient medical care delivery for 70 years and that efficiency will allow Kaiser to handle any increase in its Medicare load fairly easily.
I recall talking once with a nurse supervisor in a San Diego nursing home about one of her elderly patients, a sweetheart of an old lady.
“It’s the ‘only more so syndrome,’” she said. “She was a sweetheart of a person when she was young. Now she’s old, she’s the same, only more so! And that’s true of nasty old people. When they were young, they were nasty, now only more so.”
Kaiser Permanente started in 1945 with a single surgeon and a 12-bed wooden hospital in the middle of the Mojave Desert giving occupational health services and emergency care to the workers building the Los Angeles Aquaduct. It has now grown to a national force of almost 17,000 physicians and more than 170,000 employees. Lalich is responsible for 175 family physicians (FPs) and 75 general internists.
So I guess Bernstein’s point is that Kaiser has had to be competent and on the ball for decades to fight the fee-for-service lobby of the American Medical Association (AMA) and all those who initially felt Kaiser Permanente would destroy the doctor-patient relationship. And now they will comfortably use that engrained efficiency to service the increase in Medicare patients.
“If a patient comes in to see his or her family doctor and mentions, incidentally, a skin lesion that is causing concern, the FP can pull out the high resolution camera that every Kaiser Permanente doctor is provided with and send a digital image to one of our dermatologists for an opinion,” Bernstein explains. “We do that 34,000 times a year and because we are not fee-for-service, there’s no charge!”
Kaiser is working with Qualcomm Corporation on a pilot wireless app that will help diabetics monitor their care. It’s one of the four components of Kaiser patient care that makes Bernstein proud:
• Hospital inpatient care
• Patient-based traditional office call care
• Home care monitoring with nurse visits when necessary
• Mobile Health Vehicle Care — Kaiser has an equipped RV-like vehicle that can deliver health services at worksites.
Lalich makes the point that not only do two-thirds of his Medicare patients have co-morbidities but his FPs have been following those patients for many years in a totally integrated way. “For example,” he says, “I saw a Medicare patient yesterday who came in because he had a piece of broken glass in his foot. His chart showed us, however, he was overdue in colon cancer screening, had not had a flu shot and needed a tetanus, pertussis and diphtheria booster. He left with the piece of glass removed, his shots and an appointment for his cancer screening.
Lalich stands at the Kaiser Permanente San Diego Guinness Wall of Records and grins. I wonder if he will actually try for the Baby Boomer Medicare enlistment record. He may not need to go looking for it
t may come to him without his looking!
“All our FPs have lists,” he says, “lists covering the 64 preventive care measures we follow that make a difference. Consider diabetic care. I have a list of all my diabetics, and a list of those whose glycohemoglobins are or are not satisfactory, including those who don’t have a normal blood pressure. It’s a legacy-based excellence and it all goes back to the days of Dr. Sidney Garfield, the founder of Kaiser Permanente.
Kaiser Permanente indeed has a history, one that Bernstein covers in his book Courage To Heal. A Novel that he wrote in 2008. It includes details of the lawsuits the AMA and the California Medical Association (CMA) brought against Kaiser for, amongst other things, the alleged unprofessional conduct of using a medical group to treat patients rather than providing an individual doctor. After reviewing the quality data of decreased mortality and the improved health outcome results of Kaiser, the CMA dropped all charges.
Fee-for-service institutions still see the Kaiser approach as threatening their existences. Their fee-for-service stand is supported by patients who are comfortably off and have health insurance almost as perfect as that of our politicians’. But the reality is our health care system is broken. We need change.
It was Albert Einstein, himself, who said: “Insanity is doing the same thing over and over again and expecting different result.” And how can people with integrity not shudder when they read Time Magazine’s “Bitter Pill: Why Medical Bills Are Killing Us”?
We do need change.
The San Diego Kaiser doctors feel they are more committed than many physicians to change.
“We have to,” says Bernstein. “With the increased costs patients are facing for health care we have to find economies in how we provide it.”
Bernstein and his San Diego Kaiser doctors have been wearing a YES button on their lapels for three years. It is their mission to be read by their patients:
You make a difference
Excellence in Service, Access & Quality
San Diego’s #1
One problem I have is to what extent the Kaiser and Sharp Rees-Stealy Medical Group will help lower-income, ethnic and immigrant elders. Will those patients enjoy the Yes button as well? Time will tell. Bernstein looks at me and says, “Yes!”
This is a very vulnerable group of elderly and their future needs, as they age, concern sociologists greatly — and should concern compassionate physicians also.
It seems both medical groups, the busiest in San Diego, are saying the same thing about the Baby Boomers who are heading their Medicare way: They have become efficient. Such efficiency will allow them to expand. They have anticipated the increase. They are ready. And as President George W. Bush (unfortunately) once said, “Bring ’em on!”
Maybe. Bush, we know now, spoke too soon. But those two groups in San Diego seem confident they can prove Alvin Toffler, the author of Future Shock, wrong when he declared, “Man has a limited biological capacity for change.”
America’s doctors need to prove him wrong. But, even then, I don’t think they realize the amount of critical change that is truly needed!
(Disclosure: Nancy, my wife, an RN and nursing educator, has been with Kaiser Permanente for about 30, and Bernstein, a board-certified head and neck surgeon and otolaryngologist — and the San Diego Area Medical Director of Kaiser Permanente sitting opposite me — actually operated on Nancy for otosclerosis in the 1990s.)
Eric Anderson, MD, lives in San Diego. He is the one-time president of the NH Academy of Family Practice. His commentaries on aging are part of the MetLife Foundation Journalists in Aging Fellows Program organized by The Gerontological Society of America and New America Media. Anderson was a senior contributing editor at Physician’s Management from 1983 until 1998 (when the magazine ceased publication). He wrote a monthly column for both Postgraduate Medicine and Geriatrics for many years. Anderson is the only physician in the Society of American Travel Writers. He has also written five books, the last called The Man Who Cried Orange: Stories from a Doctor's Life.