Thursday, April 1, 2010

Is Kaiser the Answer?

The question is, how is health care to be organized in the United States? One answer by the health cognoscenti has been, why not Kaiser for everyone? It is less expensive than other care, and its quality is high by all measures. So, why not Kaiser?

Since I am in the biggest Kaiser neighborhood in the country, Oakland, and since Kaiser with probably 70% or so of the private market is our biggest competitor, I’m hardly a disinterested bystander. We lose patients to Kaiser all the time, and there is not much we can do about it. They’re cheaper, and they are not out and out bad. So, grain of salt is indicated.

But, believe it or not, I have a Kaiser card myself! Why I have that card sheds light on the travails of health insurance for a business, the business in this case being Bayside Medical Group, that fine leader in primary care in the East Bay.

I have the card because we had to get Kaiser insurance for our group. We used to have a pretty good plan, although too expensive because all health insurance is too expensive. It was an exchange program run by the Pacific Business Group on Health, very much like the Health Insurance Exchange to come under Obama care. Under the exchange, we had several different levels of care, HMO’s and PPO’s, and several health insurance companies competing at each level. Most of our employees chose Kaiser, mostly because it was the least expensive alternative, and probably also because with one stop bureaucratic shopping, it is a pretty transparent system to the patient.

Anyway, it was fine, but then the system died, mostly because the health insurance companies didn’t need it and it exposed them to too much competition and squeezed them into categories of care. So it died. So we were back to choosing a plan for our group. But how to choose? We are a disparate group, from file clerks to physicians, and one plan won’t fit all. Moreover, we are a medical group, and medical groups are avoided by health insurance companies because of a perception that they are high utilizers. And, here’s the killer – the health insurance companies insist that we go all with them, or not at all with them.

Because so many of our employees were already with Kaiser, it would be very hard not to choose Kaiser. And luckily, Kaiser has a plan whereby employees can choose the classic closed panel Kaiser plan, or opt for a so-called point of service plan, which is like a PPO. It’s expensive for both premium and deductible, a rather crappy plan to be sure, but at least it’s a plan that I can use and a few of my colleagues as well. Under this plan, I get two cards – the POS card, and a regular Kaiser card. So, here I am, a prime Kaiser competitor, someone with a distaste for large institutions such as Kaiser, a pretty independent person, and I’m a card-carrying Kaiser member. Who’d a thunk it.

So there I was with a Kaiser care, so I figured, why not make a site visit? So last year I got the first annual physical of my life – I’m not a big utilizer, and I just programmed my own preventive program – at Kaiser. Then this year I returned for my second site visit, following up with the same doctor I saw last year.

What was it like? Did Kaiser appear to me to be a possible answer to the question? That is, we know that introducing a model is not easy and often impossible, so just because something works here doesn’t mean it will work there – there are all kinds of cultural questions involved. But, that’s not the question for the site visit. The question is, if it were possible to work toward something like this, would that be a good idea, in my eyes?

I have to say that the website worked well for me. I could find a doctor who was open and find out credentials, if not much more – see our website,, for what is possible with a personal touch. And I could make my appointment on line, which was great, just great.

But when I got there, it’s a visit to what socialized medicine would look like. Big institutions, big hallways, big buildings, milling crowds, big parking lots with lots of cars one after the other and you’re just another one of them, and a full dose of the hoi polloi. No matter what you had achieved in life, there you were with everyone else on an equal footing. We have to expect that Kaiser will never be the answer for everyone, just as all the socialized systems have alternatives of private care for those who can pay. Hoi polloi doesn’t work for everyone. Probably not for me. But, if I got past that and found a system and people who worked well, it could be for me. I’m opened minded enough for that, maybe.

Although maybe not. If I or a family member get something severe, I want choice. For most non-medical people they can’t use choice very well, but for me, I can use it and will – and actually did, for my hip resurfacing, for instance. But for primary care and run of the mill, I could do Kaiser, I think. Maybe. If it were good.

Overall, I did get promptness for my primary care visit. I got Oakland African-American sullenness from my first Medical Assistant – they are unionized, and no one can really fix this – but the one at my second visit was better. They take weights with clothes on, but I guess that’s just adult care. Doctor promptness was good, although the second time I went the office was almost empty of patients, so I had to wait almost 15 minutes in the exam room for my doctor. As everywhere, work expands to fill the time, and if things are slow, the staff are likely to go slower as well.

Promptness does not apply to waiting for lab tests or immunizations – I had to wait 15-30 minutes for both, and the shots are given at a separate clinic rather than at your primary care doctor’s, with another hoi polloi exposure. And waiting for labs is as slow as on the outside. Everyone there knows about it and deals with it.

The website helped right at the doctor’s office where she could make a dermatology appointment on her computer for me later the same week – great convenience. And after the visit I got emails pointing me to my lab results on the website. I could email my doc to ask for her reaction to the lab tests.

But of the vaunted Kaiser health system, that’s kind of it. It was up to me to inquire about the lab tests, she didn’t do anything about them unless I asked, even when my Vitamin D the second time was much lower than the first time, when she put me on a supplement for it. I had to remind her this year to check my level, and also the thyroid level, which she forgot she was monitoring and had supplemented. When I reminded her to order it, she even forgot she had had me on it for a year and treated it as a new prescription. She told me to come back in three months the first time but there was no prompt for me to do so – saving money, probably (I think that’s what most of Kaiser is geared toward.) Same with the yearly physical – up to me.

Kaiser is supposed to emphasize prevention. (They are prepaid, so they advertise with a slogan “Thrive!” They probably would like to add, “If you’re sick, why not enroll elsewhere?”) So, as my doctor sat on her little cart performing data entry with her Electronic Medical Record in front of her, she attempted to perform some prevention. She said, “You’re watching you weight?” I said, “Actually, I’ve gone up in my weight lately.” I think my BMI had gone up from 27 to 30 as they measure it, after my knee surgery, which knee she didn’t think to examine. So she looked at me and kind of shrugged. That was it for weight control, despite the fact that I have arthritis and am on statins and blood pressure medicine.

You would think that Kaiser would make a point of screening for depression, given that it is so widespread and treatable. But I don’t think their much into minds and feelings. I was surprised they don’t administer questionnaires. Maybe the hoi polloi won’t fill them out, but I would have. So she screened me verbally. She looked at me and said, “You’re OK, right?” I said, yeah, pretty much. Well, it was quick.

I actually can’t remember if she did a full body physical exam or not. She sure didn’t look at the sites of my operations, or ask how my hip was doing since the resurfacing operation. I do have to tell you, however, that my prostate got a good working over. Oh, yeah.

She did check this time to see if I had had my Adacel and pneumovax shots, which I guess we had skipped the first visit for some reason. The EMR at Kaiser does work well for that.

Actually, I like her. She’s a young woman from Haiti and went to a good medical school and seems nice enough. But I tend to like people. And if there were some big issues I would bring them up, I suppose. But to me, it just seems like working in these clinics is a killer. It’s institutional. What we want is really another human being taking care of us. Can I look at Marie as taking care of me? Only if she followed up the labs, asked me to come in again, gave me a roadmap of my health care, took time to ask about me and my family and my happiness or my plans to retire – I guess she did ask about that, actually. She’s a lot younger than I am and after all, I’ve only met her twice. And I’m prejudiced, hoping that Bayside can give better care than this system. But I have to say, you can put technology into the equation – and you should – but you have also got to find a way to get institutional feel out of the equation. Institutional feel kills the essence of care, and we have to be cared for. That’s what people want, to be cared for. We’re a long way away from being able to be cared for by a HAL.

I always tell our group, the key to being a successful clinician is for your patients to feel that you are competent, that you care, and that you are reliable. It’s hard to say that any of these criteria have been met by my experience at Kaiser. The quality measures cited by the cognoscenti, indicating that Kaiser’s care is of high quality? They are just markers that can be measured. Being cared for? They don’t really measure that, just as they don’t measure the competence of a clinician or a system in chasing down difficult diagnoses, following up orthopedic issues with physical therapy, and a myriad of other aspects of quality of care. Measurement of health care quality isn’t to the point where we can rely on it to indicate good care, just where it can indicate bad care.

But I also have to say, I still have the remnants of my depression-scarred father in me, and I appreciate that Kaiser cost less than other alternatives – all I had to do was pay the copay for the visit, which was reasonable, and nothing extra for the labs. I guess it’s good enough for the hoi polloi.

So, it's an interesting site visit. We can't get more out of it than that. Just one experience, just one doctor dealing with a difficult patient, another more-senior doctor. No big conclusions. It seems as though I could find another doctor if I wanted to.

But I have to say, as a system meeting the needs of a nation, leaves me unimpressed. But then, I'm a tough critic.

As for me, looks like I'll be taking care of myself for a while longer.

Budd Shenkin

1 comment:

  1. Kaiser would do well to look at your post and work on these issues. Then again, it might make them even more competitive with you.

    Many industries are learning, especially in this tought enonomy, that caring for the customer can yield a competitive advantage. Health care providers have not faced competition like the rest of the market and have not been forced to turn to customer service for competitive advantage. With the cost of health care rising at twice the rate of inflation, people are choosing based on price rather than quality of care and customer service.

    I thought your comments on quality of care were insightful. The industry has more work to do in this area.

    As usuall a great post. Keep it up.