One of my favorite things to do is ask “why?” in everything I do, and I have found that some of the best answers to that question come from learning about who and where we came from.
There’s actually a whole series of posts on this blog tagged with “where we came from.” In them, there’s a theme that today’s problems are often not unique (helping me to patient in their resolution). There’s also a theme that those who came before us set a direction for success that is worth knowing about (helping me to maintain fidelity of purpose).
With that in mind, I eagerly read The story of Sidney R. Garfield, MD, cited as the physician father of the Kaiser Permanente health system and innovator in four key areas of health care: Prepayment, Multispecialty Group Practice, Prevention, and Information Technology.
Part of my eagerness is the fact that I didn’t enter medicine with the intention of being a Permanente physician; I didn’t even know what that meant, until the end of my residency, when the Group Health medical group in Seattle became the Group Health Permanente Medical Group.
All I knew at that time was that I enjoyed an approach to medicine that provided patients exactly what was needed – no more, no less, to maximize benefit and minimize side effects. This was and is a simple enough formula in my head – where did it come from? Is it better? If it is how should it be spread?
Sidney Garfield’s “a ha” is described in the book as a simple change to his payment scheme as a physician – when he could not afford to keep a 12-bed hospital in the Mojave Desert open on worker injuries alone, he accepted an arrangement with the insurer of the Colorado River Aqueduct project. The arrangement was a nickel a day per worker prepayment for injury treatment (to abate high costs from transporting injured workers to Los Angeles for care), followed by the addition of a nickel a day per worker for comprehensive care. The rest is history. An innovative physician discovered that he could increase his revenue stream by discovering the causes of injury in the workplace and preventing them before the patient was injured.
In short, Garﬁeld reversed the traditional economics of medicine, in which physicians are paid only when a patient is ill. Instead, Garﬁeld would beneﬁt by keeping his patients healthy and accident-free. It was a lesson he would remind himself of in later years with a newspaper clipping he kept in his desk drawer describing the tradition in ancient China, where a physician was paid only while his patient was healthy, not while his patient was ill.
Garfield also recognized an acute change in the transition from training in academic medical center – from collaboration across specialties to the solo practice model, and sought to replicate this in private practice:
“It has always seemed a paradox,” said Dr. Garﬁeld in later life, “that in universities, which teach us medicine, we learn medicine under the highest type of group practice, but when we go out into practice, we revert to the old type of individual private practice.” Dr. Garﬁeld’s great contribution to the evolution of group practice was to layer onto it the additional power of two other elements: prepayment and integration of the medical group with what he termed “adequate facilities” — “bringing the doctors’ oﬃces, laboratory, X-ray, and hospital … all together under one roof.”
And in this model of care, the promise of computers seemed a perfect fit, as Dr. Garfield wrote about in Scientific American in 1970. Even before dreaming of the electronic medical record, though, hospitals were designed by Garfield with the intention of “The patient’s record reaches the doctor before he [the patient] does.”
The story details fairly significant challenges in the development of Permanente Medicine, from the lack of acceptance by mainstream medicine, to later conflicts between physician and business interests that grew along with the success of Kaiser Permanente.
Beyond the origins and creation of Permanente Medicine, I had a few other questions that were answered….What is the origin of the “Permanente” name?:
It was so named, at Bess Kaiser’s suggestion, after a beautiful wild creek on the San Francisco Peninsula, on the bank of which the Kaisers had a private retreat. The Spanish name — Permanente Creek — came from the fact it had a year-round ﬂow of water, unlike many in California that dry up in the arid summers.
I also had questions about the spread of the model – what should be proprietary and what should be shared? This quote caught my eye:
You know institutions tend to become static; they build walls around themselves to protect themselves from change, and eventually die. You should ﬁght that by opening up your thinking and your ideas, and work for a change.
And so, here we are in 2009, Tweeting and blogging about our ideas publicly. As to whether people have followed in his footsteps, I was impressed to read this quote:
Garﬁeld summed things up from a patient point of view in a simple phrase, “The people of this country … don’t want to get sick.”
And then realize that I had sent this tweet last week, before reading the book, after taking a tour of one of Kaiser Permanente’s regional call centers. I sent it because every aspect of the design of this virtual care system was based on providing maximum value for the patient’s time. This doesn’t show that I’m as bright as Sidney Garfield; I think it shows that the entire system reflects his vision in 2009, and obviously so to this observer.
Given my Kaiser Permanente affiliation, I don’t want to imply that Garfield is the only visionary in health care. Far from it. Feel free to post about the visionaries in your care system (whether you are a provider or a receiver of care in that system) in your comments.
Reading the book is a good reminder that for as many problems as there are in health care today, there are as many Sidney Garfield’s in every health care institution and community, and they have a lot to teach us.