Just Read: Can Physicians Manage the Quality and Costs of Health Care? The Story of the Permanente Medical Group

To know where you’re going, it’s important to know where you came from….

This book, published in 1991, gives a physician’s eye view of one of the most significant health movements in the United States – prepaid, integrated health care with a social mission.

Before reading the book, I already knew that part. I didn’t appreciate its scope in American consciousness, though:

On one occasion, Avram Yedidia, the Health Plan representative, observed a distinguished looking man working quietly on some papers while waiting for an appointment with his physician at the Permanente Hospital in Oakland….Yedidia asked him if he were satisfied with the medical attention he was receiving from the Plan. The gentleman said that he was. Yedidia then asked if he minded the waiting. No, he did not, the gentleman replied. He understood how busy the doctor was. Yedidia then introduced himself, and asked the man’s name. He was Enrico Fermi, a professor of physics at UC Berkley and a winner of the Nobel Prize.

A few more quotes about the genetic code, revealed in the book:

On April 14, 1941, the first keel of the first freighter, the Ocean Vanguard, was laid…that freighter was the first of 1490 vessels to be constructed in Kaiser Shipyards over the next 5 years. in the case of the Robert E. Peary, launched in November, 1942, less than 1 year after Pearl Harbor, the time between keel laying and launching was reduced to 7 days, 14 hours and 29 minutes.

This level of social organization and cooperation was matched by a program of medical care equally organized and disciplined. The intense social cooperation of the shipyards inspired and sustained a practice of medicine comparably characterized by innovation and social cooperation. When it was over, a new way of practicing medicine had emerged.

As early as April 4, 1945, Sidney Garfield outlined them (the genetic code) in a speech to the Multnomah County Medical Association in Portland, Oregon

(here they are, summarized)

  • Prepayment
  • Group practice
  • Adequate facilities
  • A new economy of medicine (“By having the healthy pay to maintain their own health, capital coaslesced with which to care for the sick”)
  • Voluntary enrollment with dual choice
  • Physician responsibility in management as well as medical matters

Medical education, not a new idea…

There was even talk of establishing a medical school in San Francisco after the Stanford Medical School moved south to Palo Alto.

Kaiser Permanente did not mature with ease. There were lots of conflicts along the way, detailed in the pages throughout. This is in large part why people who say the core element is prepayment don’t understand what Kaiser Permanente is.

In the end, this is the place people came to. The answer to the question in the title is an unqualified yes.

No matter how the principles of our plan our meant…if you don’t have the physician group who have it in their hearts to make it work and who believe in prepaid practice, it won’t work. This is the thing that makes me wonder about HMOs all over the country. They aren’t going to work unless they get men in those operations who really believe in giving service to the people. – Sidney Garfield, MD

I am suggesting, (Cecil) Cutting reported to the partnership on October 13, 1969, that they not put their foot in it unless they can put their heart in it also. That is, first to be convinced of the principles, philosophy, and desire to provide good medical care at reasonable cost – to take pride being part of an organization that is making the medical dollar go a little bit farther.

Yes, that is a 90% Hypertension Control Rate

The results are in from what is considered the report card for health plans in the United States, and these results are kind of amazing.

I was reminded of this when I was at the #DesignForAction conference in Washington, DC, where in one of the sessions about health, the current United States’ rate of blood pressure control was bemoaned to be around 50%. This figure is sadly true.

Except at Kaiser Permanente.

Like I said, amazing. The number is 86% across Kaiser Permanente, 91% for the number one health plan in the nation, Kaiser Permanente Mid-Atlantic States, which is also number one in 7 other measures.

In the Medicare population, it’s even higher, 94% across Kaiser Permanente, 95% in Kaiser Permanente Mid-Atlantic States.

-> 95% <-

That means that 5% of Medicare members do not have their hypertension under control. Unheard of.

The 50th, 75th, 90th, and 95th percentiles for blood pressure control are


Every Kaiser Permanente region is above the 95th percentile.

Breast cancer screening, similar story

Kaiser Permanente Mid-Atlantic States is #1 in the nation at 90%, every Kaiser Permanente region is number one in the state it operates, except for Kaiser Permanente Northern California (88%). It’s #2 to Kaiser Permanente Southern California (88%) 🙂 .

Overall, Kaiser Permanente is number 1 in 21 measures, out of 83 total measures, across 5 domains of care.

News, Views and Moves from Kaiser Permanente

Source: Kaiser Permanente Share | Being the Best Saves Lives: Kaiser Permanente Leads the Nation in 21 Quality Measures

Photos from “Which Health Care Metrics Matter?”

Which Health Care Metrics Matter? Explored gaps between quality data and its use by the public to improve health and health care. (View on Flickr.com)

With great thanks to the team from Mid-Atlantic Permanente Medical Group, Kaiser Permanente Mid-Atlantic States (@KPMidAtlantic), NCQA (@NCQA), National Quality Forum (@NatQualityForum), and the medical directors/health officers of the health authorities of Maryland, Washington, DC, and Virginia: Joshua Sharfstein, MD (@DrJoshS), Joxel Garcia, MD (@HealthDiplomacy), William Hazel, MD (@VaSecofHealth)


And, congratulations Kaiser Permanente Mid-Atlantic States for its 2014 ranking of #13 out of 500+ health plans in the United States.

FWD: emr (a conversation with my brother about the RAND study on EHR adoption and quality improvement)

I received this e-mail from my brother, who is an (excellent) ophthalmologist practicing in a fee-for-service environment:

Hey ted,

Just saw this on the net, kinda confirming what my conversations have been with doctors (though can’t speak for hospitals).  The study didn’t address cost savings though, as I’m sure some duplication of tests can be avoided.

There has been some (very slow) integration of emr into offices here.  My main contention is still the focus on data collection by the govt,


what do you think?

As I mentioned in my last post about conversations with my brother (FWD: More on HIT and cost saving (NOT!), Arizona is a long way from Washington, DC, and as I have always said, the reality of health care is what happens where the patient is.

He was referring to the study recently released by folks at RAND. I reviewed it, provided some commentary, and here was his response.

I agree with you, that the cost savings and quality improvements depend on implementation.  The few docs I know that are going emr, are in it for the govt discount, and of course, chose the cheapest, most basic system that is clearly worse than paper charts at this point.

Also, a good point with the duplication of tests.  Even though a test was normal 3 days ago, we’re still legally liable to repeat it.

Integration with physicians is surely the way to enhance our health care delivery; as long as it’s done right.

There were some doctors elected to the new congress.  Hopefully, that will help.

So what did I think?

I think the article makes a good argument that an EHR by itself is not transformative (you can read commentary on it here). There’s an important clue embedded within:

Sixth, our study may not have been long enough to fully estimate the relationship between EHr adoption and quality improvement. Institutions with “homegrown” EHrs that have been developed and refined over decades typically report that their EHrs have significantly improved clinicians’ adherence to recommended practices. In fact, our analyses are some- what illustrative of this phenomenon, as we observed that hospitals that had a basic EHr in place at the outset of the study realized significantly higher gains in heart failure quality scores.

In other words, there’s the data, and then there’s what you do with it. Quality does improve with leadership experience, and that will happen over time.

Not just technology, leadership, Kaiser Permanente, Tualatin, OR

Look at the data in this study – the first of its kind – showing the impact of measuring and introducing “care gaps” into clinical practice, at Kaiser Permanente, Northwest. The study looked at 13 different care recommendations and found that after 20 months, the PST improved performance from 72.9 percent to an average of 80 percent.

That’s a very different conclusion. Why? Look at the photograph on the left. You could only understand how an EHR helps by physically going to the place where it is used. When you do, you discover all the things in the environment around the technology that makes it work, like leadership and commitment. And it does work, with results to show for it. You can read more about my experience here: The ability to know – Population care facilitated by health information technology at Kaiser Permanente Tualatin, Oregon.

I suggest looking beyond the data, just like the design thinkers do – the value of observation.

I don’t want to imply that the hospitals studied in the RAND article lack leadership or commitment – referring back to what my brother asked, it’s the goal of EHR implementation to open the physician and patient community to the commitment they have always had, enabled by great tools.

In Conclusion, I don’t know what to tell my brother, yet

I need to sip my own champagne and “observe what people don’t do, listen to what they don’t say,” so I’m going to shadow my brother in his practice of medicine, where his patients are. 🙂

I’ll report back; in the meantime, what would you tell him?

How provider competition can improve health care delivery – McKinsey Quarterly – Health Care – Strategy & Analysis

How provider competition can improve health care delivery – McKinsey Quarterly – Health Care – Strategy & Analysis – A good overview of some of the evidence around the benefit of competition in specialized and not so specialized care. Relevant to those interested in reducing information assymetry. Of relevance to those interested in personal health records: “We believe that it is time for health systems to shift their focus toward unleashing competition in primary care; that is where competition is likely to make the greatest difference.”

Presentation: Using Technology to Achieve Total Health – Aligning Forces for Quality #af4q

Here is this morning’s presentation for the Aligning Forces for Quality meeting in Orlando, Florida ( @AligningForces ). I’ll follow up with another post with links, etc. See everyone in a bit!

I have posted images and links from this presentation in this post, if you would like to access the resources mentioned below.