Kaiser Permanente, the largest HMO in California, presented two very different faces in the late 1990s.
Publicly, it promoted itself in an advertising campaign as a health maintenance organization whose patients were “in the hands of doctors.”
Privately, according to internal documents, Kaiser was making it difficult for its Northern California patients to see doctors.
The documents, largely minutes of private meetings and doctors’ e-mails, highlight a Kaiser culture that for years equated managing care with making it inconvenient to get.
The papers, obtained by The Times from a union and a consumer group, provide a rare glimpse into the inner workings of an HMO as it struggles to attract and retain customers in one of the most competitive health care marketplaces in the country.
One of the most striking of the documents describes the Northern California operation’s long-standing practice of making patients wait for doctors’ appointments to save money and “control demand.”
Dr. Robert Pearl, chief executive of the physician group that treats 3 million Kaiser patients in Northern California, candidly described how “we chose not to provide our patients with what they desired,” according to minutes of a private meeting last spring.
At a meeting last summer, Pearl told his physician group’s board of directors that this way of doing business had left patients and doctors dissatisfied--and wasn’t saving money. He said it was time to change.
In a recent interview with The Times, Pearl said Kaiser had become a leader in improving patient access. But that, internal documents suggest, meant breaking with the past.
Using ‘Wait Lists’ to Control Demand
“Historically,” Pearl told the Permanente Group board, according to the minutes of a July 2000 meeting, “we believed that making patients wait for a routine primary care appointment was less costly and would lower utilization. . . .
"[W]e believed that wait lists for specialty consultation were the best means to control demand.
"[W]e also believed that, if we were to supply enough urgent care appointments to match expected demand, that demand would only increase and we would again be short of appointments.”
But, Pearl said, those assumptions proved wrong. No money was saved, in part because the vast majority of patients persisted until they got past a cumbersome telephonic triage system that stood between them and their doctors. Most got appointments on the same day they sought them. All who persisted, Pearl said, were eventually seen.
Not only did the approach fail to discourage large numbers of patients, Pearl said, it also was inconsistent with a Kaiser’s new long-term business strategy. In the mid- and late 1990s, the HMO began seeking to reposition itself in the marketplace as a high-end HMO with the goal of becoming a “leader in quality and service.”
“This will be a challenge for us, given that historically we have been viewed as low-cost, low-service and often low-quality,” he said.
The repositioning was the result of a long self-examination by Kaiser that involved focus groups and marketing consultants and led to a national advertising campaign in 1998.
The crux of the campaign was a claim that Kaiser was distinctive because its patients--unlike patients in other HMOs--were “in the hands of doctors.” The main idea was that Kaiser doctors could decide which treatments to provide without having to get clearance from insurance company bureaucrats.
Some patients and a consumer group, the Foundation for Taxpayer and Consumer Rights, took issue with the claim, alleging in a lawsuit that Kaiser doctors’ treatment decisions are also financially motivated. The suit is pending.
But the slogan struck some Kaiser employees as problematic for other reasons.
At the same time that the “in the hands of doctors” slogan was being launched, Kaiser officials were redesigning their approach to patient care in Northern California to emphasize increased use of non-doctors.
A Kaiser official who was involved in designing the new approach expressed the worry in a 1998 e-mail that the greater reliance on non-doctors did not square with the slogan. The official, Cecilia Runkle, fretted that “members are currently having difficulties getting timely access to their physicians.”
“The tag line may promise more than we can deliver,” she wrote to a Kaiser official involved in the advertising effort.
Runkle’s e-mail was turned over to the consumer group in the course of its lawsuit, which alleges that Kaiser engaged in illegal false advertising.
Kaiser denies it was misleading anyone and cites, as evidence, an independently conducted consumer survey showing that its Northern California members rated Kaiser above average in the late 1990s in terms of access to care when compared to other major managed care plans. Southern California members rated Kaiser’s accessibility about average.
Still, e-mail exchanges among Kaiser doctors in the late 1990s show them grappling with vexing patient access problems, frustrated at their inability to provide patients with adequate care.
Too Few ‘Gatekeepers': Primary Care Physicians
The private e-mails were supplied to The Times by the consumer group that is suing Kaiser and by the California Nurses Assn., a union that represents the 10,000 Kaiser nurses in Northern California.
The e-mails show that, in early 1999, when the ad campaign was in full swing, doctors and members at Kaiser’s Santa Rosa facility were upset. Santa Rosa was swamped with new members who were being told there were not enough primary care physicians--the traditional gatekeepers for care--to go around.
"[P]atient assistance has been deluged with scores of complaints daily from patients, many of whom are new members, who have been told they must wait to get a new doctor,” Dr. Richard Zweig wrote colleagues.
“In many peoples’ minds, having a PCP [primary care physician] is the same as getting access to care and they feel we have cheated them by denying them both access and a PCP,” he continued. “Some are throwing their Kaiser cards at the patient assistance staff.”
Zweig explained in an interview that at the time Kaiser was short-staffed; some doctors had quit and had not yet been replaced.
Two dozen doctors and nurses from the Napa-Solano area also wrote in 1999 to Pearl, the chief executive of the Northern California physician group, to ask that the primary care physician-to-patient ratio be trimmed.
“From the point of view of our members and patients,” these doctors and nurses wrote, “they hope for personalized care when they join Kaiser Permanente. . . . With a primary care physician-to-member ratio of 1 to 3,333, it is frankly impossible to provide.”
Last January, the ratio was reduced to 1 per 2,748, prompting Zweig, an internist and rheumatologist, to remark in another e-mail: “We are making progress, but we still have a long way to go to reduce panels to a level which will enable us to offer the level of care our patients expect and with which we will feel professionally comfortable.”
Another doctor in Santa Rosa, family physician Michael Sweeney, wrote in a February e-mail that, although the ratio had been reduced, doctor workload remained unmanageable because of a new “open access” policy in which primary care physicians were required to reserve more appointments for last-minute patients from the pool of patients assigned to them.
Sweeney reflected that, in the past, it had been easier to let some of those patients be seen in urgent care clinics, for example, by doctors to whom they were not assigned.
“We may have had 3,300 members per doctor in 1997,” he wrote, “but we weren’t doing open access, nor were we taking care of all of those patients. We were trying to put a great many of them off and never see them, especially those who weren’t actually assigned [to a primary care provider].
“Now we are trying to care for all of our individual patients. The job is much bigger now.”
Sweeney said in an interview that, even in 1997, all patients who wanted to see doctors were seen. But when telephone triage clerks determined that patients calling in were not very sick, they often referred those patients to see doctors other than their own primary care physicians at less convenient times. “It was more of a hassle [for patients] than it needed to be,” he said.
State Rules Mandate Doctor-to-Patient Ratios
California regulations require that managed care plans offer a primary care physician-to-patient ratio no higher than 1 to 2,000.
Kaiser officials explained that the ratios discussed by doctors in the e-mails are weighted. One sick patient, for example, might be counted as two healthy patients, one doctor said. The actual ratio of primary care physicians to patients, a spokesman said, is more more like 1 to 1,500.
In an interview, Pearl said that Kaiser has recently made it substantially more convenient to get care.
“Particularly in the late 1990s and onto the present, we have been the leader at making access easier,” he said.