American College of Physicians: Internal Medicine — Doctors for Adults ®

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California: shaking things up

Kaiser comes of age with new take on access

From the April 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Deborah Gesensway

Kaiser Permanente grew to its current position of prominence by promising quality care at the lowest costs. Patients figured it was worth the inconvenience that comes from large bureaucracies, big clinics and hurried doctors.

California-style, cutthroat managed care in the 1990s, however, has turned that winning formula on its head. First, other health plans started undercutting Kaiser on price. Then, patients began to check out all the new HMOs entering the market. So now, the granddaddy of managed care is completely revamping how its doctors provide health care services to a third of all Northern California residents with health insurance. The overarching goal: winning and maintaining membership through customer service.

That means in Santa Rosa, for example, that patients who fill out a form at the receptionist's desk saying they were unhappy with their visit will get their co-pay refunded. Explained Sharon Levine, MD, associate executive director of The Permanente Medical Group in Oakland, Calif., this little innovation makes doctors "very aware of how they are coming across. Having a bad day has different implications." The money refunded comes out of the department's budget.

In Sacramento, this new "open access" philosophy means, in part, that starting last month internists have been assigned to work full-time either on the wards practicing inpatient medicine or in the clinics concentrating on outpatient medicine; they will not do both. Advocates of the change feel the old system slights patients in both places, but more tellingly, they say the new system promises to cut hospital lengths-of-stay further and free clinic doctors from medicine call--because that service will now be covered fully by the hospital-based specialists.

"Open access means that if the patient wants to be seen, the patient gets seen," explained Mark Sheffield, ACP Member, an endocrinologist who is sub-chief of internal medicine at Kaiser Permanente, Sacramento. "Instead of having the patient go through a whole lot of hoops, we now say if a patient wants to see a doctor today, he sees a doctor today. If a member calls and says, 'I want to see Dr. Sheffield,' we say, 'When?' We don't say, 'Are you sure you want to see him?' Or 'We don't have your chart.' Or 'He's at lunch.' The competitive pressures are here to make us do this."

Once "open access" takes full effect in the next few months, internal medicine subspecialists like Dr. Sheffield will be expected to be accessible and available to primary care physicians late evenings, weekends, whenever. At one Kaiser Permanente clinic in Northern California this is accomplished by having one doctor of each specialty accessible by cellular phone round the clock. "Our orthopedists have a 'bonephone'; the dermatologists carry a 'skinphone.' If you are a primary care doctor and you have a patient who has a rash you can't deal with, then you call [the specialist] and either describe it or they come down to your office right then and take a look at it," said Dr. Levine.

The Northern California region is the largest of Kaiser Permanente's 12 somewhat independent regional systems. Its nearly 3,500 physicians take care of 2.5 million patient-members; the region handles 35,000 patient visits each day.

"It's the notion of max-packing a patient's visit," Dr. Levine said. "When a patient comes in to the doctor, it's the doctor's responsibility to take care of any needs that can be identified right then, so that they won't come back next week for something else."

"This is a real shift for the medicine profession, which has had a very profession-centric view of what health care and medical care ought to be," Dr. Levine continued. "The old model was that we had to manage demand. The new plan is to just open the doors. ...The hope, of course, is that it will engender loyalty among our members. The marketplace will be the test of that."

Kevin Walsh, ACP Member, is one general internist now trying to adjust to this new way of practicing medicine-- and he sees a downside for both physicians and patients. For the last five years, he has seen patients in the Kaiser clinic at Rancho Cordova and, as they got sick, followed them into the hospital in nearby Sacramento. No longer. When a patient of his is hospitalized, all he can do is pay a social call and keep in touch with the hospital-based specialist who will take over the case.

"I think this is going to weaken the doctor-patient relationship to some degree," Dr. Walsh said. And, he adds, he is going to personally miss the change of pace that comes from working in different settings. "There's been a growing economic pressure to do more with fewer resources. That has been the driving force behind a lot of the dissatisfaction that I feel."

Dr. Walsh has lost more than just hospital work in recent years. When he started five years ago, a general internist could spend part of his day doing treadmills, flexible sigmoidoscopies and other procedures. "That's pretty much all been taken away," Dr. Walsh said. "Now, believe it or not, the nurses do the majority of the flex sigs and treadmills. RNs. It works out fine. I don't think there is a quality issue at all, and it saves a lot of money. But I don't get to do them. So basically, right now, I am nose-to-the-grindstone in clinic with patients... And the message is that everybody is going to be working harder. That's just the way it is going to be."

Although he mourns some of these changes, Dr. Walsh says he also applauds others. He is most excited about a plan to reorganize his clinic into a "comprehensive primary care" office, where the doctors will work together with a nurse practitioner, psychologist, health educator and social worker/case manager, who will all take care of a population of patients together.

"The idea is that if I have a sense that there are some psycho-social factors influencing a patient, I can just walk down the hall to my colleague and hook that patient up with the social worker. Or if I have a patient with diabetes that isn't very well controlled, I can hook him up with the health educator right then and there," Dr. Walsh said. "This is very exciting."

Also encouraging physicians is talk among Kaiser executives of dramatically reducing the health plan's investment in hospital buildings. There are discussions about consolidating services at some of Kaiser's 17 hospitals throughout the Bay area and Sacramento to deal with the problem of too many beds. For the first time also, some Kaiser patients and physicians might be found in non-Kaiser institutions. "The most valuable capital investments in the future, we believe, are going to be information systems, not bricks and mortar."

Said Dr. Sheffield, "Adapt or survive--that's the issue... Kaiser was the model for HMOs, and it represents a good model, but only to the extent that it can shake some of the inertia it had. ... Now we're being asked to meet competitive demands."

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