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About Kaiser Permanente ins.
"As a health care organization in the 21st century, we have a mission--to provide quality care for our members and their families, and to contribute to the well-being of our communities. See how we dedicate ourselves to this mission.
Kaiser Permanente ins is the largest nonprofit health plan* in the United States, serving 8.2 million members in 9 states and the District of Columbia. We are an integrated health delivery system, which means that we provide and coordinate the entire scope of care for our members, including:
- preventive care
- well-baby and prenatal care
- immunizations
- emergency care
- screening diagnostics
- hospital and medical services
- pharmacy services
- providing assistance to the uninsured and special populations
- training new health professionals
- introducing new delivery methods into the health care field
- developing and sharing better ways of caring for patients
A tradition of community involvement
Introduction
Health care organizations, including Kaiser Permanente, have become a main feature of many political campaigns and have received a great deal of media scrutiny.
As a service to our members and health care consumers in general, we offer these answers to frequently asked questions about medical care. We hope that this provides the information you need about important health care issues, and how Kaiser Permanente provides care.
Medical decisions
Q.
Who makes medical decisions at Kaiser Permanente?
A. At Kaiser Permanente, medical decisions are made by physicians and their patients working together. The doctor-patient relationship is the foundation of our care.
Q.
Does Kaiser Permanente use "gag clauses" that prevent physicians from discussing health care options with their patients?
A. Kaiser Permanente ins strongly opposes "gag clauses" that prevent physicians from discussing treatments not covered by the Plan, possible referrals outside the Plan, or how physicians are compensated. Our physicians are encouraged to tell patients about all the treatment options that are available, no matter what the Plan covers.
Keeping information from patients to benefit a health plan's bottom line is ethically wrong and forces patients to second-guess their practitioners. At Kaiser Permanente, our physicians use their clinical expertise to let patients know about the full range of treatment options, and to help patients take an active role in health care decisions.
Physician compensation
Q.
How are Kaiser Permanente physicians compensated?
A. Our doctors are compensated as a result of a two-step process: (1) Health Plan pays the Medical Group; and (2) the Medical Group pays the doctors. A summary of these steps is provided below.
Health Plan pays the Medical Group
Each year at Kaiser Permanente ins, the Health Plan and the Medical Group in each region negotiate and agree on the total amount of money that is estimated will enable our physicians and other clinicians to provide the amount of professional medical care that our members are expected to need in the upcoming year. This estimate is based on the previous year's performance (and the years prior to that), and also includes administrative and other expenses associated with operating the Medical Group.
That total is then divided by 12 months, and then divided by the number of expected members in the coming year. That calculation results in an amount of money (the "capitation") that the Health Plan pays to the Medical Group on a monthly basis for each member.
In addition, the Health Plan reimburses the Medical Group for its actual cost for certain medical and other expenses that may be difficult to forecast, such as transplants and contingent expenditures. The total is called the "basic contractual payment."
In the event that the total of all payments, as adjusted throughout the year, is insufficient to provide the needed care, Kaiser Permanente dips into its reserves for shortfalls. Then, during the following year, dues may be raised and reserves replenished. If the basic contractual payments, including the capitated payments, are greater than the actual cost of the necessary medical care, then the Medical Group, as a whole, is permitted to share in some of the surplus.
The remainder is retained by the Health Plans to fund reserves, build hospitals and/or other medical facilities, keep dues lower than they otherwise would be, and the like. Some of the regional Health Plans also reward a Permanente Medical Group for improvements in member satisfaction and/or improvements in preventive medicine or other quality standards.
Medical Group pays the doctor
After the Health Plan pays the Medical Group, the Medical Group uses that money to pay its doctors and other personnel, and to meet its other expenses.
The primary compensation method used by all of the Medical Groups is salary. Salary generally varies with medical specialty and tenure. Smaller amounts of additional compensation may be paid for, among other things:
board certification
achievement of specified clinical quality measures
achievement of member satisfaction levels
productivity
continuing medical education
managerial work
work performed in excess of normal work time, etc.
In addition, in some Medical Groups, the excess money that the Medical Group retains, if the basic contractual payments exceed the actual cost of care on a regional basis, also may be used to pay additional compensation to doctors and other personnel.
As of 2002, approximately 95 percent of physician compensation was paid in salary.
This is a summary of the arrangements between each of the regional Health Plans and Medical Groups and each of the Medical Groups and their respective doctors. These arrangements vary by region.
Some people believe that capitation payments carry an incentive for preventive medicine to keep patients healthy. Other people believe that capitation payments provide physicians an incentive to withhold treatment.
We believe that our compensation process does not create an incentive for our physicians to make patient care decisions based upon factors other than the medical needs of the patient because Kaiser Permanente's form of capitation is based upon:
collective performance, rather than the individual performance of a physician, and
Permanente physicians are compensated primarily by salary.
Medical care and prescriptions
Q.
I've heard that HMO administrators pressure physicians to discharge their patients from hospitals, including women who have undergone mastectomies. What does Kaiser Permanente do?
A. At Kaiser Permanente, clinical decisions are made by physicians working with their patients. The decision of how long a mastectomy patient stays in the hospital, or whether a hospital stay is recommended, is based on what is medically and psychologically appropriate for each individual patient.
Outpatient mastectomies (in which the patient goes home the same day of surgery) are becoming more common, and many women choose to recover in the comfort of their homes, with appropriate support, instead of in the hospital.
Kaiser Permanente does not require mastectomies to be performed on an outpatient basis, and there are no restrictions on coverage for overnight hospitalization, if this is what the physician recommends. If, after surgery, a patient's medical or emotional state indicates the need for an overnight stay, this care is provided. Our highest priorities are the successful outcomes of surgeries, and the emotional well-being of our patients.
Q.
I've heard that HMO administrators pressure physicians to discharge their patients from hospitals, including new mothers and their babies. What does Kaiser Permanente do?
A. At Kaiser Permanente, clinical decisions are made by physicians working with their patients. The decision of how long a mother and her newborn baby stay in the hospital is made by the physician in consultation with the mother, based on what is medically appropriate for the mother and child. If there is a medical reason to extend the stay, our physicians decide with patients when discharge is appropriate.
Each year, Kaiser Permanente is responsible for nearly 80,000 births. We have the experience and the data to demonstrate that having a baby at our hospitals and medical centers is a safe and satisfying event. Kaiser Permanente focuses on promoting good health and regular care throughout a woman's pregnancy—including quality prenatal and postnatal care.
Many mothers and newborns can leave the hospital within 24 hours from birth. Many women prefer the comfort of home, away from the noise and disruptions of the hospital, for recovery.
Q.
Recently I've heard a great deal about HMO drug formularies that restrict patients' access to necessary pharmaceuticals. Does Kaiser Permanente use a formulary, and who decides which drugs are included?
A. Kaiser Permanente has developed prescription drug formularies—lists of drugs that have been approved by review boards of Kaiser Permanente physicians and pharmacists--to ensure that appropriate medications are available for our members, while also providing these drugs cost effectively. Kaiser Permanente's formularies are doctor-driven and quality-based.
As an integrated delivery system, Kaiser Permanente seeks input from the entire range of health care specialties in developing our formularies. In doing so, we evaluate each medication for:
safety
effectiveness
patient convenience
patient compliance
effect on the number of calls and visits to physicians, emergency rooms, and hospitals
quality of care
number of side effects
as a last consideration, cost
Quality of care
Q.
I've heard that the quality of care provided by HMOs is inferior to that provided under traditional, fee-for-service coverage. How does Kaiser Permanente ensure quality?
A. At Kaiser Permanente, one of our top priorities is to continually improve the quality of health care we provide. By coordinating patient care and working closely with their fellow physicians, the Permanente Medical Group physicians lead the way in improving clinical practice, conducting medical research, and improving overall health care quality for our members and our communities.
Access to care
Q.
I've heard that HMOs deny patients access to care in order to please Wall Street investors and ensure their profitability. Is this true for Kaiser Permanente?
A. Because we are a nonprofit health plan, Kaiser Permanente is not publicly traded. We do not have shareholders and, therefore, can invest our resources in providing affordable, quality health care for our members and the communities we serve.
Learn more about who we are and the structure of Kaiser Permanente.
Other concerns
Q.
I've heard that HMOs don't provide coverage for the poor and the uninsured, and don't participate in medical research. How does Kaiser Permanente address these important social goals?
A. We contribute to a wide range of community programs and activities across the nation. These efforts include:
providing health coverage through our dues subsidy programs to those who otherwise could not afford it
providing subsidies to help individuals and small employer groups afford health coverage
contributing to medical knowledge and to the improvement of clinical care nationally through our clinical and health services research projects
offering education and training programs for physicians, nurses, and other health professionals
partnering with local governments to meet community needs
providing grants, equipment, expertise, and volunteer hours to community organizations
Kaiser Permanente has established a national program for uninsured children. We devote a minimum of $30 million annually to subsidize health care coverage for uninsured and underinsured children, with a goal of helping 70,000 children each year.
Advancing medical knowledge through clinical and health services research is a key part of helping to improve the health of communities. Our community investments support research for important medical and social needs such as:
preventing violence
preventing infectious disease
improving health care for adolescents
improving health care for underserved populations
For nearly 50 years, Kaiser Permanente researchers have turned modest grants into major discoveries that have served our communities, influenced national policy, and affected medical practices throughout the nation and the world.
Learn more about our community involvement.
Q.
I've heard about an HMO consumer bill of rights and other HMO reform legislation. What is Kaiser Permanente doing to address consumer concerns?
A. Kaiser Permanente has joined the American Association of Retired People, Families USA, HIP Health Insurance Plan, and Group Health Cooperative of Puget Sound in proposing consumer protection principles.
Kaiser Permanente, with the American College of Emergency Physicians, also supports national legislation that would assure appropriate access to emergency medical services. We believe that a single national standard should be developed so that the costs of conflicting or duplicate federal and state enforcement measures are reduced.
At Kaiser Permanente, one of our core values has always been to improve the health of the community, as well as the health of our members. For nearly 60 years, we have shown our commitment to this through a variety of programs and activities.
We know that good corporate citizenship benefits our communities. Social responsibility and community involvement are part of our legacy, and are crucial to our mission-caring for the communities we serve and making them better places to live and work.
Through partnerships with community groups, schools, and government organizations, we work to benefit the community at large by addressing issues and concerns that affect its overall health.
In the desert, a new kind of health care begins to grow
Kaiser Permanente began at the height of the Great Depression with a single inventive young surgeon and a 12-bed hospital in the middle of the Mojave desert.
When Sidney R. Garfield, MD, saw the thousands of men involved in building the Los Angeles Aqueduct, he also saw something else-an opportunity to provide health care for those workers. He borrowed money to build Contractors General Hospital, six miles from a tiny town called Desert Center, and began treating sick and injured workers. But financing was difficult, and Dr. Garfield had trouble getting the insurance companies to pay his bills on time. And though not all of the men had insurance, he refused to turn away any sick or injured worker. As a result, often he was not paid for his services. And it wasn't long before the hospital's expenses were far greater than its income.
Back to top
Enter Harold Hatch, an engineer-turned-insurance-agent. Hatch approached Dr. Garfield with the idea that insurance companies pay a fixed amount per day, per covered worker, up front. This would solve the hospital's immediate money troubles, and also let Dr. Garfield put one of his pioneering medical ideas into practice: emphasizing prevention. By keeping people healthy and treating them early on to prevent more serious problems later-rather than merely treating illness and injury-Dr. Garfield introduced a new kind of care.
And so, along with preventive care, prepayment was born. For only 5 cents per day, workers received this new form of health coverage. For an additional 5 cents per day, workers could also receive coverage for non-job-related medical problems. Thousands of workers enrolled, and Dr. Garfield's hospital became a financial success.
But this was just the beginning.
At Kaiser Permanente, we understand that traditional health care-treating illness-isn't enough. We encourage our members to thrive, no matter what stage of life they are in.
Whether it's preventive care, health education classes, or appropriate treatment, we support good health by providing personalized care every step of the way.
We want our members to receive the kind of care that we would expect for ourselves and our families. That's why we work hard to design programs that measure the quality of the health care we provide.
Our commitment to excellence
At Kaiser Permanente, we are committed to providing our members with quality, cost-effective health care. Our physicians and managers work together to improve care, service, and the overall performance of our organization.
Our team approach
We believe in a team approach to providing high-quality care and service. In our distinctive approach to health care, our physicians and other health care team members work together to share information and expertise.
This approach helps make it simpler for our members to get referred to one of our specialists. In addition, our approach to health care typically provides many types of medical services under one roof, making it more convenient to get care. In some cases, we also will refer our members to other specialists in the community so that we can provide the most appropriate care.
For highly specialized care, we concentrate our resources and expertise at certain locations, so our members can get care from doctors who are well trained and well practiced in these specialties.
Our practitioners
Good health care begins with developing a relationship with a personal physician or nurse practitioner from one of our primary care departments. We encourage all our members to choose a personal practitioner, who will provide and coordinate all medical services.
Our excellent medical professionals are dedicated to providing compassionate, personal care. We put them through a rigorous, selective hiring process. This helps ensure that we select skilled medical professionals with whom our members will want to build long-term relationships.
Once they become a part of Kaiser Permanente, our medical professionals receive ongoing training in their specialties as well as in general patient care. This includes cultural sensitivity training, new technology education, and education in our accepted best practices.
Our advanced research and technology
When we work to improve health care, we go beyond our medical offices and into the research labs.
Our physicians and researchers have developed innovative programs and technologies that are being used every day in hospitals and clinics across the country. Our research in important areas such as colon cancer, osteoporosis, heart disease, and immunizations has led to new ways of screening and treating millions of people, as demonstrated by our Disease Management Program.
We're also unveiling a new automated medical record system that will enhance the quality of care for all our members. Once our automated system is fully operational, it will give our medical team access to a member's medical history at the touch of a button. " - kaiserpermanente.org