Finally, Tom Got Better When He Was Treated At Stanford, Not Kaiser
Today I talked to an old friend and season ticket partner at our annual divvy up the Giants tickets meeting. I said, “Tom, you look great! My God, is it retirement?”
He said, “I'm well for the first time in 10 years!”
“What's up with that?”
“I was sick and I didn't even know it.”
So he told me his story. Key to the story – he was a Kaiser patient. He did what he was supposed to, went to his appointments, was feeling gradually worse and worse, and they told him that his liver tests were getting worse and worse. Tom isn't particularly a drinker. They tried to adjust his life style. They didn't tell him what was wrong. Finally, Tom left Kaiser and went to be treated at Stanford. Tom said that within three days, they had gotten to records and studies done at Kaiser and done a complete workup on him, including MRIs. They found that Tom had extensive AVM's (arterio-venous malformations) in his liver, that he had the underlying condition of ameloidosis, and that he had impending heart failure. They put him on the liver transplant list and he stayed there for a year, moving up from number 265 to the 100's. It would be a while.
One day they called him in and said that they wondered if he would consent to be the first patient at Stanford, and the second in the United States, to undergo a liver transplant done completely by robotics, pioneered by the Japanese. They would be importing one of their specialists from Japan to supervise the operation.
“What's in it for me?” asked Tom.
“Well,” they said, “you would move up in the waiting list.”
“How far would I move up? “ he asked.
“You would be number one,” they said.
Well, that was a question that answered itself, of course. He consented, they moved him up, and within three weeks he had his operation. Now, a year later, he couldn't feel better – and, I would add, he couldn't look better.
Oh, yes, Stanford also discovered in the Kaiser notes that they had indeed discovered the AVM's over ten years previously, and they had in their notes that they had not informed him of what they knew.
One of the major differences between Kaiser and Stanford is how they are paid. Kaiser is a prepaid integrated network, where they get capitated patients per month, no matter what costs they incur. Stanford is paid in the traditional fee for service system. You can see the difference in their advertising. Kaiser advertises, “Thrive! We will keep you healthy!” They want well patients. Stanford, on the other hand, boasts in their advertising how adept they are in handling illnesses. “Have a bad heart? Come see us at Stanford!”
Did anyone at Kaiser really care about what happened to Tom? Not according to their notes and his course. If you are a prepaid plan, you depend on well patients, and treating sick patients costs you money. Did they decide that Tom was untreatable? Treating patients aggressively in Kaiser depends on professional ethics, since the financial incentives cut the other way. In addition, I don't believe that Kaiser has a system for organizational learning. If they make a clinical mistake, does it get fed back to the members of the organization so they can improve, and perhaps feel bad about what they missed? I don't think so.
Do they care more at Stanford? I don't know. My anecdotal evidence is that they are superbly organized for things such as knee replacements, and that they show great compassion. But anecdotal evidence is just that, not to be trusted.
It is sobering to think that Kaiser, and other prepaid integrated care systems, have been lionized for years as the serious and sober and cost-savings way to go. It's an old-fashioned construct – the efficient factory, units coming through. The latest iteration is Medicare Advantage, where plans can make money by denying care – as Kaiser did with Tom – as well as over-billing, which they specialize in. The government is actively promoting Medicare Advantage, despite evidence that it is costing them money. Private business interests, especially health insurance companies like United Healthcare, are influential and benefit from Medicare Advantage.
Tom looked great and felt better.
Budd Shenkin
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