KAISER
PERMANENTE THE UNAUTHORIZED TOUR AND DOCUMENT SUMMARY
©
C.
Phillips and V. Travis 2006
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KAISER
PERMANENTE
THE
UNAUTHORIZED TOUR
AND
DOCUMENT
SUMMARY
©
C. Phillips and V. Travis 2006
KAISER PERMANENTE
THE UNAUTHORIZED TOUR AND DOCUMENT SUMMARY
© C. Phillips and
V. Travis 2006
SECOND EDITION June 2007
(Permission Granted to Copy if -C. Phillips
–
contact information:Cphil49401@aol.com
is
notified and told of probable distribution and this front page is
used each time to protect the copyright)
Published
by
LULU.COM
Printed version
published in the United States.
Second Edition
Dedication
-
This book is
dedicated to Adam Wesley Arnold who died on September 11, 2000. He
was a typical senior and he was painfully sacrificed on the altar of
HMO greed.
It is our
deepest desire that all that
read the
contents of this book will gain knowledge,insight and perhaps
avoid the experience that Mr. Arnold had to endure. It is unlikely
that the public will ever be able to out fox the fox. There are
too many checks, balances and retaliatory acts in place for that
to be allowed. By seeing the HMO for what it actually is the
public can best avoid becoming another intentionally
mislabeled
statistic whose sacrificial experience will only be remembered as
data presented before Congress for the purpose of an HMO to either
obtain grant money or another sizable health related contract.
Our
reward for this effort is to make HMOs transparent so that their
ability to hurt people is brought to the attention of the public.
Whether the solution will come from the voters, the journalists, the
politicians, the lawyers, the judges, or somewhere else, HMOs will
someday be viewed as a huge step backward in health care. And those
who spent decades coming up with hidden methods of withholding care
from the elderly will be properly viewed as some of the most evil
people ever to have lived on this earth.
Table
of Contents
Section
1 - Introduction
Section 2 - SHORT
SUMMARY
Section 3 - DELVING DEEPER
Section 4 -The History of Kaiser Permanente;
Section 5 - The Permanente physicians – the
real power at KP
– Sidney through Robbie, and now Jay;
Section 6 - Kaiser CEOs – Henry through
David, and now
George
Section 7 - The Kaiser Plan and Hospitals using the same
Board, CEO, President, Chair man of the Board, top executive
committee, tax accountant,
audit firm, legal team,
ad advertising,
etc.;
Section 8 - Advertising Promises;
Section 9 - KP First Tag line –
Permanente
Medicine (rather
than HMO);
Section 10 - Second Tag line –
Not-for-Profit;
Section 11 - Third Tag line – Physicians
Know Patients "You
can do it, Dana."
Section 12 - The Permanente Map – Blueprint
of Permanente
(thus Kaiser also as the Enabler);
Section 13 - The Genetic Code – Permanente
as a Fragile
Being (competing with the patient for resource allo cation/restriction);
Section 14 - Overextending Everyone’s
Training – Janitors
through Physicians;
Section 15 - "Team Care" – Physician as
Coach;
Nurses and Pharmacists Give Primary Care;
Section 16 - Physician Recruiting – Rags to
Riches;
Section 17 - Medical Malpractice Covered By the Plan;
Section 18 - Government as Kaiser’s Rich
Uncle;
Section 19 - California Helps Kaiser Float $3 Billion
in
Bonds;
Section 20 - Beltway Relationships – White
House, Congress,
and Supreme Court;
Section 21 - Agencies Help Kaiser – HHS,
NAS, AHRC (the
"arc"), CDC;
Section 22 - Shadow Government Agencies Help
– The
Forum, G-7, the Robert Johnson Foundation, EPCs in Oregon and
North
Carolina, etc.;
Section 23 - Bankruptcy Case of Dr. Moses –
Protecting
Retirement Riches;
Section 24 - Kaiser Physician Sues Kaiser as KP
Leaves
Kansas City – Physician Insider’s Point of
View;
Section 25
- Kaiser Permanente
Ventures –
Hospital and Permanente Partners;
Section 26 - Analyzing Kaiser’s 990 Form
"Charity"
Activity vs. IRS Intent;
Section 27 - The Kaiser Family Foundation –
Not
Independent of KP;
Section 28 - Controlling Universities with Money and
Endowed Positions;
Section 29 -
The Pill Splitting Case – "After
Market" Medication Tampering;
Section 30 -
Changing Lab Values Report to
Congress and
HARP;
Section 31 - Clinical Practice Guidelines –
Cheapest
Care Possible;
Section 32 – Kaiser Hospice and Nurse "Closers"
– Double Morphine Syringes;
Section 33 - Patient Loses Leg at Kaiser –
Poor
Differential Diagnosis and Tampered Lab Testing;
Section 34 - Huge Potassium Doses and Un sterile Home
Care by a "Closer" – the Vickie Travis
Story about Her Dad and his death;
Section 35 - Wrong Care for Prolapsed Cord
– Baby
death in Oakland;
Section 36 - Wrong Care of Pre-eclampsia –
Baby death
in San Diego;
Section 37 -
Jamie Court’s Book –
Making a Killing
- Too Many Infants with Paralyzed Arms (Erb’s Palsy
Babies) due
to Midwife Use for Difficult Deliveries;
Section 38 - Kaiser and Employees –
Missing
Endometriosis and other Diagnoses;
Section 39 - Kaiser and Employees – Forcing
Employees to Stay with Kaiser’s Work Comp for One
Year;
Section 40 - Kaiser and Employees –
Benefits (losing
years of records to pay a nurse less in retirement);
Section 41 - Kaiser and Employees – Safety
vs.
Asbestos;
Section 42 - Kaiser and the Medical Board of
California;
Section 43 - Kaiser and the California Medical
Association;
Section 44 - Kaiser and the Department of Managed
Health Care
in California;
Section 45 - Henry Mead Kaiser - $2 million fraud
– had to
quit Kaiser Plan/Hospitals Board in 2004;
Section 46 - Kaiser and Dirty Endoscopy –
the Hepatitis C
Story.
Section 47
– Kaiser's Industrial
Clinics Share Diagnoses
with Employers - (e.g.,
Saying that one patient had al coholic hepatitis –
which was actually delayed Hepatitis C for
which the patient never got help and died.)
Section 48 - Conclusion
Sources
Section
1. INTRODUCTION:
Perhaps the best
introduction to the Kaiser HMO
and Kaiser
Permanente Medical Care Plan is the summary by Mr. Edgar Kaiser that
the less Kaiser does for patients the more money it makes.
To get the full context one can go to the University of Virginia and
review the presentation Mr. Edgar Kaiser (then Kaiser CEO) made
to President Nixon through Mr. Ehrlichman – the less we do
the more
we earn. This convinced President Nixon to go forward with the HMO Act
of 1973 with Kaiser as the template. The conversation is
recorded below within the Nixon White House Tapes.
John
D. Ehrlichman: “On
the … on the health
business …”
President Nixon:
"Yeah."
Ehrlichman:
“… we have now
narrowed down the vice president's
problems on this thing to one issue and that is whether we should
include these health maintenance organizations like Edgar Kaiser's
Permanente thing. The vice president just cannot see it. We tried 15
ways from Friday to explain it to him and then help him to understand
it.”He
finally says,
“Well, I don't think they'll work, but if the President
thinks it's
a good idea, I'll support him a hundred percent.’”
President
Nixon: "Well, what's … what's the judgment?"
Ehrlichman:
"Well, everybody else's judgment very strongly is
that we go
with it."
President Nixon: "All
right."
Ehrlichman: "And, uh,
uh, he's the
one holdout that we have in the whole office."
President
Nixon: "Say that I … I … I'd tell him I
have doubts about
it, but I think
that it's, uh, now let me ask you, now you
give
me your judgment. You know I'm not to
keen on any of these
damn
medical programs."
Ehrlichman: "This,
uh, let
me, let me tell you how I am …"
President
Nixon:
[Unclear.]
Ehrlichman: "This …
this is a
…"
President Nixon: "I
don't [unclear]
…"
Ehrlichman: "…
private enterprise
one."
President Nixon: "Well,
that appeals to
me."
Ehrlichman: "Edgar Kaiser
is running his
Permanente deal for profit. And the reason that he can … the
reason
he can do it … I had Edgar Kaiser come in … talk
to me about this
and I went into it in some depth. All the incentives are toward less
medical care, because …"
President
Nixon:
[Unclear.]
Ehrlichman: "… the
less care they give
them, the more money they make."
President
Nixon:
"Fine." [Unclear.]
Ehrlichman:
[Unclear] "…
and the incentives run the right way."
President
Nixon: "Not bad."
The
preceding transcription is from the University
of Virginia:
whitehousetapes.org/pages/listen_tapes_rmn.htm for
the clearest possible presentation.
Check:
February
17,
1971, 5:26 pm - 5:53 pm, Oval Office
Conversation 450-23. Look
for: tape rmn_e450c. It is 12 MGS if using Windows Media
Player
[Kaiser
brags elsewhere that the HMO Act of 1973 was
largely designed around its model. In many ways all of the US HMOs
are Kaiser clones. Most, like Kaiser, have the hidden at risk formula
whereby the physicians get a large benefit – really kickback
–
for every premium dollar saved (unspent).]
Section
2. SHORT SUMMARY:
[Note
- As many reporters, attorneys, and others would like to have a several
page summary of Kaiser to get the big picture before delving
into details, this Short Summary is next provided.Following that,
much more detail is given. All in all, the total information
available about this secretive HMO can now be turned into an
encyclopedia.]
“Kaiser Permanente” is simply a for profit
BUSINESS PLAN (only a concept and not a registered business entity or
taxable entity) trying to be viewed by patients and the press as a
not for profit "Medical Care Plan." The goal of KP is to
appear to be part of the mostly medical “Mayo
tribe” and not the
for profit, mostly business “HCA tribe.” Though
such patter is
parroted as being like the Mayo Clinic and the media.
Kaiser
does fail in
this image attempt. Most people do correctly see Kaiser as a for
profit machine with very impersonal and marginal-at-best care
according to inside interviews conducted by Kaiser.
So Kaiser has to spend $40,000,000 a year in its ad Thrive campaign
hiding the business agenda just to keep its membership
flat. Kaiser cannot seem to get to 9 million members goal they
once had, and the public is moving away from HMOs anyway. Patient
autonomy of health care decision and HMOs secrecy and
gatekeeper control don’t mix.
One third of the time Kaiser care is acceptable, but that is aimed at
special people and meant to keep the outside inspectors confused about
the two thirds of the time that the care is way below acceptable
– often lethal. Kaiser has the Capacity to give care
– reflected in the notebooks presented for the
outside inspectors (as the latter folks look forward to the sliced beef
tenderloin lunch) – but not the Will do so, as there
are less profits in doing it right.
Inspectors
don’t know – or don’t want to know - the
difference (and I [Dr. Phillips] watched an inspection of Kaiser from
the inside).
The
two parts of KP are:
1)
The FOR PROFIT “Permanente” physicians
“Federation,”Inc.
headed by Dr. Francis “Jay” Crosson, who is really
in charge with
Kaiser family control weakening (See
Section 45), and
2)
The classic
"Kaiser" which includes both the Kaiser Foundation Plan and
the Kaiser Hospitals - using the same CEO, President,
and Chairman of
the Board – Mr. George Halvorson - and the same Board members
(always with a Kaiser family representative as
part of the board).
Might as well be the Crosson-Halvorson business plan. Huge profits
are planned and achieved each year - $1.8 billion
for 2004 - half to
Crosson's partner shareholder physicians and the other half to
Halvorson's hospitals.
Dr. Crosson
–
for consumption in England - describes KP as a "partnership"
in the article
“Kaiser Permanente: a
propensity for
partnership” at
http:bmj.bmjjournals.com/cgi/content/full/326/7390/6547.
In
his description
each physician knows the “bedside and the
boardroom” [read as the
patient’s wishes vs. the more important business
goals].
Yet,
to
the United States IRS, Kaiser declares the KP relationship as one of
contracting agent (the Kaiser Plan) and contracting business
(Permanente) at an “arm’s length
separation” with real
negotiating going on and NOT a partnership. This inconsistent duality
is allowed by the IRS as part of government’s total refusal
at
every level to regulate this HMO. The IRS could always choose to
revisit this relationship and confiscate $5 billion in past taxes.
This is a real risk as mentioned in the prospectus for
Kaiser’s
bond
offering.
Business
principles ("the group ethic")
prevail in every setting from the boardrooms in Oakland overlooking
Lake Merritt to the physician offices from Maryland to Hawaii. And as
all of the budgets for the various Kaiser locations across the
country are prepared in and later reported back to Oakland for
national budget tax presentations, the various urban expressions of
Kaiser Permanente - like the Denver area - are simply "portals"
of the organization, a term used by Kaiser. [The particular reference
for the surprise, overnight movement of Denver mainframe IT to
Oakland is found in the article “Kaiser – Shock
Therapy”
article on Dr. Lawrence; Denver had previously tried to be somewhat
independent since they made the most profit per enrollee.] Kaiser
delays its 990 year end tax form an extra six months each year
–
thus coming out in October –because
of the
complexity of handling in Oakland the tax issues for each area of
Kaiser around the country. Kaiser’s representation in states
is
really in areas where they can achieve profit – thus cities.
In urban settings
Kaiser can achieve the re quired 50,000 patient base allows the Kaiser
physicians to refer internally to other Kaiser physicians for specialty
care – the double gatekeeper
system.
Kaiser does
not really offer near to
statewide
service, except in much of California where 75+% of all Kaiser
patients live. Kaiser buys into metropolitan areas when they expand
to a new state – e.g. New York City and Washington, D.C., the
latter was a buy out of a Humana plan leaving the city, and
http://xnet.kp.org/permanentejournal/fal98pj/fall98pjword.html
Dr.
Jay Crosson and Mr. George
Halvorson work several doors away from each other on the same, 26th
high rise in Oakland at 1 Kaiser Plaza. The Plaza includes
a nice restaurant looking out at a large, second floor park not
seen from the street. All the floors can look down on the park on
one side, Golden Gate Bridge in the background or Lake Merritt on the
other.
Mr.
Halvorson commutes up from Alameda rather than coming down from the
hills as did Dr. Lawrence. As to who is most in charge, one need
only read Mr. Halvorson’s acceptance speech in coming to
Kaiser and having Dr. Crosson welcome him on board. Kaiser has always
had internal physician control way back to Dr. Sydney Garfield's desert
clinic during the Depression (with which he made $50,000 in
personal profit each year used to buy apartment buildings in Los
Angeles).
Dr.
Crosson’s and Mr.
Halvorson’s names appear
jointly on many projects, such as the switch from the IBM CIS IT
system of Colorado to the EPIC IT system used by Kaiser with
Oregon Health Sciences. [Kaiser’s infiltration of
universities is
discussed much later in Section 28.] As the two men are the
co-chairs of the top executive committee at KP, when both names
appear on documents it is as final as it will get.
The
Plan/Hospitals board is more of a rubber stamp. Expect to find Kaiser
on both sides of the negotiations with EPIC system in Wisconsin with
which it now “partners.”; IBM was less likely to
allow
Kaiser to profit elsewhere from its CIS product. CIS was better
medically – according to a past Permanente coder employee
– but
EPIC did a better job of billing patients (Kaiser has been
transitioning back to fee for service with its co-pays).
The
Permanente physician partners are paid from two sources at all
times:
1) a salary of about $250,000 a year to be
frugal,
clinic "cost centers" dispensing limited care, and
2)
then again perhaps another $250,000 a year for the KP profit of
withholding the care whenever and however nearly doubled in this
profit fashion so that the physician “employee”
salary is merely
a “draw” on total income of the same physician as a
Permanente
shareholder-partner.
As
such doubling would be highly taxed, much of the profit money is kept
under
the wing of the Kaiser
Plan
so it can be used for a Golden
Retirement (where the physicians can afford real medical care for
themselves and their families). Creditors cannot touch this. In
a bankruptcy case of a Dr. Moses, described later in this
investigation – Section 23 - a Los Angeles bankruptcy trustee
sued the Kaiser orthopedist (and thus Permanente system of money
protection) and lost. The trustee was neither able to get a
total figure of the money held for Dr. Moses nor to get that money
joined in his other debts. He did get close enough to call
it a millionaire’s pension; this money accumulates for care
withheld.
Pill splitting (see Section
29),
the changing
of normal lab values (see Section
30),
under reading cardiac stress tests, missing cancer until it is
"too late" and then forcing patients into hospice care,
channeling people into fibromyalgia and then undermining their self
esteem, trying to convince all chronic patients that they all have
a similar disease which is handled best by staying home and eating
fruits
and vegetables,
blaming all illness on life style, etc. give witness to the lack
of ethics on the way to conniving on how to spend less. All of
this is the opposite of the "superior" care label and
caring physician ethic painted by the "Thrive"
ad campaigns.
How does one "Thrive"with
less care?
National
Kaiser HMO care is organized by the
Care Management Institute
(CMI) in Oakland – developed in 1997
at a brief time of no
profits for KP, financed by the Kaiser Plan
(as if it is non-profit educational
adventure), and run by
the Permanente physicians for its real profit purpose.
The organizational survival plan – a patient - unfriendly
plan –
is to first defining all care into cheap "evidence"
packages (see
section 31)
and then "making the right thing easier to do" at the front
line, provider office. Independent thinking physicians in Kaiser
will only find that giving care different from the
Oakland hints will cost them so much extra office time explaining
that they will be called non-productive or "not manage care suitable."
"Kaiserizing" physicians (medical
ethic bending)
and "Kaiserizing" patients (care expectation reduction) is
part of the KP HMO process.
KP
is the corporate
practice of medicine
- from the
skyline of Oakland – which is completely
illegal in every state and
fraudulent
to every patient. In the
Hippocratic
tradition the physician can only be the patient’s advocate if
able
to practice with an independent license making ethical decisions. The
CMI’s financing is also fraudulent – coming from
the Plan and
the Hospitals as if a public "education," charitable
service(though the principle output of "evidence" protocols
is secret).
Mr.
Halvorson specifically made the already suspect "charity"
of the Kaiser Plan and Hospitals even more business related –
supporting CMI "evidence" work, educating future Kaiser
physicians, paying for
lobbying of Congress,
etc.
Lobbying is deducted as an educational effort.
Patient
fundamental rights are also compromised at Kaiser facilities,
particularly in the most important right – to know
one’s true diagnosis in lay terms bringing the patient equal
with the physician so that real options can be weighted and the patient
preserves decision autonomy. Without that there is almost never any
really informed
consent.
One can almost measure the ethics of a hospital by how hard it is to
find the patient’s rights paper required to be on the wall by
the Joint
Commission.
In one Kaiser hospital this paper is
behind a waiting room chair in X-ray where no one can read it without
standing on the toes
of a patient to get an X-ray. This is consistent with the attitude
by which Kaiser calls patients "external
customers"
– the dangerous business model that does not
fit
medicine.
In pictorial
documents Kaiser draws
its "external
customers"
(patients) as droopy and boring (most not
needing to be
there anyway); staff is then pictured as bright and professional
– a narcissistic ego
trip of its own.
Then, when the care
comes out wrong and incompetent, the records display tampering, risk
management
which makes government expert review all but impossible –
e.g. a
female necklace
appearing on a
shoulder x-ray
on
a
male patient who has
never had a
necklace. How
much tampering is done by the original physician
(who
gets the chart first), a specialist partner or Kaiser’s
legal team
(who next gets the chart) is unclear; medical
records
technicians state that the copying is not the same as copying charts
for other doctors. Once altered, the chart is then given to an outside
copying company to make it look like recipients are dealing
with an
original.
The methods of tampering include removing material, wrong patient
material, copying too small,
rearranging pages, lack of pagination forcing cut and paste to
reassemble, copying light, copying so signatures and training
won’t
show up (nurses making insulin decisions), etc. [In the medical legal
area, every Kaiser chart I have reviewed reflected serious
tampering – CP.]
Perhaps
a decade ago, the
California Supreme
Court castigated Kaiser for its unfair malpractice,
arbitration
system (See Engalla
v. Kaiser
on
HARP.org.)
The "Blue Ribbon Committee" chosen by CEO Dr.
Lawrence – with a few judges on board but still Kaiser
empathetic,
recommended inside the report that both the Kaiser attorney and
the patient’s attorney get the same records at the same time.
That recommendation was mysteriously dropped in the final version and
has never been followed!!!
Little was done except to have an "independent" legal
office run the arbitration system; the head of this office then
testified in Sacramento as to how well it was working (consumer groups
appropriately complained). Add in forced arbitration with judges who
become dependent on Kaiser income – an average of three
$15,000 cases a year supplementing their
incomes – and the system provides absolute power back to the
HMO. Absolute power leads to absolute corruption (an old phrase
restated by President
Kennedy
at Amherst
College
on the dedication of the Robert
Frost Library
where I,
Dr.
Phillips,
was simply a premed usher). Kaiser does not mind violating the
ethic of talking to the judges on the side as well – see San
Diego
arbitration case that Kaiser won (Section
38
– baby dies).
There are almost no voices of dissent left to give a balanced view
(second opinion) of Kaiser, making some call California the sarcastic
name "Kaiserfornia." The nurses are silenced
as benefits partners – the California
Nursing Association
removing from its website a very long list of Kaiser faults. The unions
become "partners" in profit – increase to
officers and silenced employees.
The regulators are
afraid of the size and
political influence
of the HMO – a $30 billion corporation (parallel in size
and finances to the VA) using "charity" funds to lobby politicians,
e.g. joining the Governor on pet initiative projects.
The
newspapers and radio shows appreciate receiving portions of and thus
are silenced by the
$40,000,000 a year ad campaigns - the
latest
called Thrive (now even part of the KP logo). They do not
even
check the basic message lies – KP as nonprofit, physicians
who will get to know you and advocate for you, trust in us
(regardless of lifestyle), etc. And the public does not understand that
the Broccoli ad is really about staying home with
your illness – all sickness at Kaiser becomes a Broccoli
deficiency.
So there is no "fourth estate" check
and balance by the media, the first three "estates" being the three
parts of government. When a reporter does get curious, he
or she is distracted by having a sudden, invited, private interview
(scoop) with the CEO of Kaiser – looking out the windows on
the
26th floor - as to his future visions that he called "Blue Sky"
(everyone stays home
and care is conducted with the computer). This
happened to the reporter from USA Today who broke pill
splitting
and the reporter from the San Francisco
Business paper who
was getting close to asking if the docs got part of the profit (CEO
Halvorson was vague on this).
Trial lawyers find the record tampering and verdict financial
ceilings too restrictive to permit the cost of expert review,
so
there are far too few cases for the number injured at Kaiser. [Many
Kaiser patients stop at the point that they must "DEMAND"
arbitration; that plays against the assertiveness of patients who
simply WANT fair compensation for incompetence and error.] And
so, the public only gets the spoon fed glories in canned news
releases; only hurt patients or their families know the reality and
the lack of justice. [Few attorneys try to sue Permanente –
but
IPAs are NOT protected by California’s MICRA
caps.] Finally, in its public 990 tax forms – required by the
government - Kaiser magnifies its IRS required obligation (to avoid
taxes) back to the public as if it is raining presents on the public.
In fact, a good deal of its obligation is spent internally on pet and
secret projects, the latter including "evidenced based medicine"
pamphlets which are so corrupt that Kaiser won’t show them to
outside physicians.
Section
3. DELVING DEEPER
[Now, for the next
level of detail the reader must take time to see the near to full
unveiling of Kaiser. There one can go on to look at the realities of
care to perhaps see the
Grand
Canyon difference
between the ad promise and the reality show.]
The
order of
topics will be:
Section
4 –
The History of Kaiser Permanente;
Section
5
– The Permanente physicians – the real
power at KP – Sidney
through Robbie, and now Jay;
Section
6
– Kaiser CEOs – Henry through David, and
now George
Section
7
- The Kaiser Plan and Hospitals using the same Board, CEO,
President,
Chairman of the Board, top executive committee,
tax
accountant, audit firm, legal team, advertising, etc.;
Section
8
– Advertising Promises;
Section
9
– KP First Tag line – Permanente Medicine
(rather than
HMO);
Section
10
– Second Tag line – Not-for-Profit;
Section
11
– Third Tag line – Physicians Know Patients "You
can do it,
Dana."
Section
12
– The Permanente Map – Blueprint of Permanente
(thus Kaiser also
as the Enabler);
Section
13
– The Genetic Code – Permanente as a Fragile Being
(competing
with the patient for resource
allocation/restriction);
Section
14
– Overextending Everyone’s Training –
Janitors through
Physicians;
Section
15
– "Team Care" – Physician as Coach; Nurses and
Pharmacists Give Primary Care;
Section
16
– Physician Recruiting – Rags to Riches;
Section
17
– Medical Malpractice Covered By the Plan;
Section
18 –
Government as Kaiser’s Rich Uncle;
Section
19
– California Helps Kaiser Float $3 Billion in Bonds;
Section
20
– Beltway Relationships – White House, Congress,
and Supreme
Court;
Section
21
– Agencies Help Kaiser – HHS, NAS, AHRC (the
"arc"),
CDC; Section 3
Section
22
– Shadow Government Agencies Help – The Forum, G-7,
the Robert
Johnson Foundation,
EPCs in Oregon and North Carolina,
etc.;
Section
23
– Bankruptcy Case of Dr. Moses – Protecting
Retirement
Riches;
Section
24
– Kaiser Physician Sues Kaiser as KP Leaves Kansas City
–
Physician Insider’s Point of View;
Section
25
– Kaiser Permanente Ventures – Hospital and
Permanente
Partners;
Section
26
- Analyzing Kaiser’s 990 Form "Charity" Activity vs. IRS
Intent;
Section
27
– The Kaiser Family Foundation – Not Independent of
KP;
Section
28
– Controlling Universities with Money and Endowed
Positions;
Section
29
– The Pill Splitting Case – "After Market"
Medication
Tampering;
Section
30
– Changing Lab Values Report to Congress and HARP;
Section
31 –
Clinical Practice Guidelines – Cheapest Care Possible;
Section
32.
–Kaiser Hospice and Nurse "Closers" – Double
Morphine
Syringes;
Section
33
- Patient Loses Leg at Kaiser – Poor Differential Diagnosis
and
Tampered Lab Testing;
Section
34
– Huge Potassium Doses and Un-sterile Home Care by a "Closer"
– the Vickie Travis Story about Her
Dad
and his
death;
Section
35
– Wrong Care for Prolapsed Cord – Baby death in
Oakland;
Section
36
– Wrong Care of Pre-eclampsia – Baby death in San
Diego;
Section
37
– Jamie Court’s Book – Making a Killing
-Too Many Infants with
Paralyzed Arms (Erb’s Palsy Babies) due to Midwife
Use
for Difficult Deliveries;
Section
38
– Kaiser and Employees – Missing Endometriosis and
other
Diagnoses;
Section
39
– Kaiser and Employees – Forcing Employees to Stay
with Kaiser’s
Work Comp for One Year;
Section
40
– Kaiser and Employees – Benefits (losing years of
records to pay
a nurse less in retirement);
Section
41
– Kaiser and Employees – Safety vs. Asbestos;
Section
42
– Kaiser and the Medical Board of California;
Section
43
– Kaiser and the California Medical Association;
Section
44
– Kaiser and the Department of Managed Health Care in
California;
Section
45
– Henry Mead Kaiser - $2 million fraud – had to
quit Kaiser
Plan/Hospitals Board in 2004;
Section
46 –
Kaiser and Dirty Endoscopy – the Hepatitis C Story.
Section
47
– Kaiser’s Industrial
Clinics Share
Diagnoses with
Employers – (e.g., Saying that one patient had
alcoholic hepatitis – which was actually delayed Hepatitis C
for
which the patient
never got help and
died.
Section
48
– Conclusion.
Everyone
will have decide to what level of information it is that they want to
pursue in understanding this huge HMO, a $25 billion corporation and a
national HMO player since for over two decades. Transparency
is the only chance for change.
Section
4. HISTORY OF KAISER PERMANENTE – Sydney and Henry
A.
Sidney Roy Garfield, MD, still called "The Founder" was the
son of parents who were born in Russia – changing their New
York City
name to Garfield;
B.
The family business was selling
clothes in New York; the family moved to Los Angeles in 1938;
D.
Sidney was more interested in engineering than medicine but fulfilled
the family expectation to become
a doctor; [engineering might
have been the better choice for him
to take
for the out come of millions of patients, but even there he
has problems – he forgot
in designing the Hawaii
Kaiser
hospital with visitor corridors on outside that there were typhoons
(hurricanes in the Atlantic ward)];
A. Sidney applied to
go to medical school at the end of his sophomore year; only one
medical school of four accepted him –
the University of Iowa;
he got his medical degree in 1928;
B. He did his
internship in Chicago and then switched to a surgical resident at the
county hospi tal in Los Angeles;
C.
When graduating
from UCLA School of Medicine and Surgery Residency, there were few open
practices in the middle of
the Depression, except to the best
graduates; however, there was a job out on the desert for taking
care of those working on the
Los Angeles Aqueduct Project to bring
water from the Colorado River;
D.
Soon Dr. Garfield
realized
that he did not want to be an employee physician but would rather be
an owner and contract for the service;
E.
He borrowed money
from his father and others and opened his own $50,000
"Contractors’ Hospital," the loyalty of which
to
business was never in doubt; he wanted "pre payment" since
"the one who pays the bills control the service." (Smillie
book
page 8)
F.
He developed
prepayment with the "San
Francisco Exchange" of large project con tractors –Bechtel,
Kaiser, and others; this was
the beginning of what would develop into
Kaiser enterprises and Garfield Physicians, finally into KP when tax
changes were re quired to protect prof-its;
G.
As to
the desert practice, "… Sydney Garfield retained earnings
from
the 5-year period [1933-1938] of $250,000. It was
an astonishing sum
in 1938 when the average annual American in come,excluding those on
relief, was $1350." [Smillie book –
page 18
H. Later Dr.
Garfield was asked to do the same for the dams going up in Washington
and Oregon; the relationship with the
Kaiser family became much
closer;
I.
Finally, in World War Two the US set up
shipbuilding for England’s insatiable (and later our) need
for
Liberty ships (one a day); Mr. Kaiser
took on the challenge –
although not a shipbuilder – and Dr. Garfield tended to the
employees, often 4F (with
health problems) and unable to go to war;
J.
In the book
Mr. Kaiser Goes to Washington one can read about Henry Kaiser, Sr.
making money off the government –
"The Rise of a Government
Entrepreneur" – Kaiser has always been about solving
government problems where after
Kaiser’s
methods were not
regulated;
K.
After the war the US government turned over the
Kaiser clinics with little charge to the prepaid health
system, one of the
many ways the
government built Kaiser up;
L.
The shipyard
towns of the West
Coast became and still are strongholds for Kaiser, 75% of the
patients always being from California;
M.
The State of
California has always helped Kaiser to grow and flourish, like no
other state;
N. Henry Kaiser,
Sr. and Dr. Sydney Garfield
ran the medical organization like a father- son team, Mr. Kaiser did
external
relations and co-signed Bank of America funding while Dr.
Garfield ran the physicians and hospitals on the inside;
O.
It was a workable
duality, and they even became neighbors in
Lafayette, California, as they married sisters: "Sidney and
Helen Garfield
moved next door to Henry J. and Alyce Kaiser in
Lafayette. Garfield and Kaiser were now brothers in- law,
married to
sisters who were extremely close to each other, visiting back and
forth every day. In the evenings, the two
couples would
gather for
cocktails and conversations. Sydney Garfield was now the
brother-in-law, physician, and close
personal confidant of Henry J.
Kaiser." (Smillie book page 111)
P.
Later the other
physicians thought it was all too comfy –
particularly when the two men developed Walnut Creek Kaiser
Hospital
without asking the others.
Q. For
decades all of the Kaiser industries were beholding to Mr. Kaiser,
Sr., and Dr. Garfield was the employer of all of the
physicians;
profits were likely split up 50-50% - the Bechtel-Kaiser approach
–
but have never been published; [Dr
Garfield’s ownership of
apartment buildings could be a good place to start].
R.
At
one point the Kaiser Family Foundation split off with a $50,000,000
endowment; of ten they have bailed Kaiser out
(e. g. Michigan) but
try to appear on the web to have no history and no relationship to
KP (see Section 27);
S.
In fact, KFF has
handy professor
chairs at universities who coincidentally always sup port Kaiser in
articles – Stanford and Harvard public
health departments
and/or
out comes research units, like Duke and Oregon Health Sciences (see
Section 28);
T.
One interesting
connection is that KFF pays
Harvard to conduct health polls and then pays the Washington Times to
run
the polls, to give KFF a national voice
in health care
(also Section
28);
U.
Sidney Garfield always managed to be part of
the
profit system; and as the Founder, he taught many ideas [few that
patients know or would like]:
1.
He had a "pencil stub club" making sure that no one got a new pencil
until the first was a stub; he expected the same of
hospital
equipment;
2.
He created the idea of the "economy of shortages" whereby you could
under-finance an area and see what creativity
or harm
developed;
3. In
1960 he talked about "New methods of providing health care as opposed
to sick care must be tested."
4. "Many patients, per Dr.
Garfield, were simply the "worried well" – Smillie book 211;
[not seeing patients any more, he
did not have
to take any license responsibility for these business views about the
evolving Kaiser Culture];
5. In 1967 it became more
clear to the Permanente physicians that the patients should be
responsible for their own health
– not KP. "…
Kaiser-Permanente helped pioneer a shift of consciousness that would
become fully evident by the
1980s
when health
was no longer envisioned as something that doctors gave patients, but
as something that healthy
members maintained
for themselves
through a
healthy
lifestyle." (Smillie
book p. 210.)
[The shift in consciousness was
internal as the
ads still promise to
this day a high level of trust – "we’ve always been
there
for you."]
V.
The federal government always helped
Kaiser. For example, when Nixon established wage and price control,
Kaiser was
allowed to escape – the doctors were only
"providers"
not employees.
W.
Later Kaiser was exempted from the dreaded
HSA certificates of need, so that they could build whatever they
wanted
without a certificate of need;
X.
Years earlier Henry
Kaiser Sr. said that the best place to start the tour of his
shipbuilding was back in Washington, DC
where all the
deals were
made (read Mr. Kaiser Goes to Washington – although the
Kaiser
family cooperated it was not an
altogether complimentary book).
Y.
By 1952 Permanente was starting to envision itself as an organism at
risk – really vying with the patient for sustaining
resources
–
and developed its own "Genetic Code" (Garfield actually
started the "genetic code" concept during speeches in
1945)
– Smillie Book 99- 101 [my comments and additions in brackets
like
this]:
1.
"prepayment" [which meant patients had to
trust the physicians];
2.
"group practice"
[sustaining the group was key and having both primary and specialist
gatekeepers controlled
costs];
3.
"adequate facilities"
[yet Dr. Garfield also said "If you don’t have enough beds in
a hospital, you are going to use them more
perfectly" (page 74
– Smillie)];
4.
and "a new economy of medicine" –
[really blaming patient lifestyle on almost all illnesses and
reducing benefits in the process];
5.
voluntary enrollment
with dual choices [Kaiser decided that its closed staff model did not
allow real choice.
Patients
should always have another plan from
which to choose. Later, this was dropped as a federal
requirement and
as an ethical idea. Many
workers now have only one choice and that is Kaiser (this even
happened to me in
2003).
6.
See more discussion in Section
13.
E.
THE TAHOE [ONE] AGREEMENT –
The
Tahoe One
Agreement is listed by Mr. Paul Wallace of Kaiser in his power
point slide history - "Making the Right Thing Easier to Do"
-as a key moment in Kaiser’s history. Original Kaiser
materials
may be found in the Kaiser Collection in the Bancroft Library
materials and UC Berkeley [plan to spend many hours to get a few
documents as librarians watch that no papers are removed or
harmed – which is good, CP]; some of the documents are also
available on the KaiserPapers.org.
Preceding
events – Walnut Creek Kaiser, Hawaii Kaiser, the Permanente
responses – power plays back and forth [See "Toward the
Tahoe Agreement p. 121-142 in Dr. Smillie’s book];
1.The
meeting at the Kaiser home at Lake Tahoe in which Henry Kaiser, Sr.
hoped to use water skiing and barbecues at his
home to
soften the physician; but that
did not work [See full chapter in Smillie’s book –
called "The Tahoe Agreement" p.
143-174 – 31 pages and the
longest chapter]
2.
Serious contest of wills in this new business "partnership;"
3.
It is all about the outcomes of sharing power 50:50 and sharing profit
50:50.
4. Author Smillie went on to describe the
minor variations since;
5. [Physicians have an
agreement with Permanente which sometimes shows up in court cases; the
special 50:50 paper is more rarely
seen – see Section 24
– "Article K" – all ten pages]
6.
Original signatures on the Working Council split can be found in the
Bancroft Library or at the KaiserPapers.org; both Henry
Kaiser and
Sidney Garfield signed [and also married sisters and lived next door to
each other in Lafayette, California].
DD.
This profit sharing is also found in Dr. Raymond Kay’s in
Historical Review of Southern California Permanente Medical
Group
(Kay’s book p. 43). The signatorts are typed out
clearly in the back of the book.
EE.
"TAHOE TWO" – ALSO KNOWN AS THE RECOVERY PLAN FOR 2001
The Balanced Budget
Act of 1997 – which ended up pulling out some $300 billion
fromthe
hospital industry - was already expected by 1996. The managed care
industry took a nose dive in lockstep in 1997 (source The Bleeding
Edge page 35) just as many small hospitals also came up short and
closed. For Kaiser this touched off two years of loss of profit,
something that had not happened before or after in its sixty year
history. There was cross blaming between the Permanente groups and
the leaders of the Plan/Hospitals. Out of this clash Permanente
became particularly stronger. The new plan was called the Recovery
Plan for 2001, which was really an attempt to not only go back into
the black but to recover the lost profits as well. (It is
also called Tahoe II.)
The
changes included all of the following and more:
1.
The Permanente Groups, then headed by the largest TPMG under plastic
surgeon Dr. Robert Pearl (internally "Robbie" – a
plastic
surgeon), were reconstituted into the Permanente
Federation with pediatrician Dr. Frances "Jay" Crosson in charge
(also
a TPMG physician), the latter with Kaiser from 1977 until
now (some 28 years);
2.
[Pediatricians are often promoted to
high levels in Permanente because they have an easy time with the
concept of
withholding adult critical and cancer care and
doing
better on HEDIS scoring, like immunizations. The image that
pediatricians are generally the nicest among
physicians
has to be
rethought.]
3.
The Federation also
developed its business arm, the PERMCO – the Permanente
Company – to handle venture
projects,
e. g. Caretouch, a
dialysis consultant role, etc. (See
Section 25)
4.
Dr. Crosson and then CEO, Dr. David McKinnon
Lawrence, were made co-chairman of the National Partnership Group,
the top executive committee
in KP – handling all issues going
to and from the (less powerful) Board; Mr. Halvorson stepped
into this
role as the new CEO, with Dr. Lawrence becoming a Board member as
"Chairman Emeritus";
5.
"Permanente Medicine: the Path to a
Sustainable Future" article by Francis J. Crosson, MD about Kaiser
published in the
Permanente Journal. The
Permanente Journal explains a lot. Dr. Crosson co-chairs the
"National Partnership Group" with
Mr. Halvorson - "a
joint body at the national level, to determine KP's national
strategy for the future" It is also the "top
executive
committee" at
KP. The formation of the committee is part of
"Tahoe Two."
6.
More can be found on the National
Partnership Group at http://www.gao.gov/medpac04.pdf.
This also includes Dr.
Goldsmith's bio
describing the Kaiser
Permanente Partnership Group (KPPG) as the "highest decision
and policy-making
body in Kaiser Permanente." Dr. Goldsmith was until
2004 the Medical Director, Southern California Permanente
Medical Group.
7.
The physicians agreed to practice with more
uniformity and less variation through the creation of the Care
Management
Institute – funded by the Plan and run
by the
physicians; the CMI became in charge of the developments of
"evidenced-based medicine," really a step down,
cheaper
version of the national standards coming out of the specialty
societies.
A.
the American
Heart Association wants every patient with chest pain – who
might be a possible heart attack – to have
oxygen; Kaiser does
not think this is necessary;
B. the American
Diabetic
Association feels that sedentary patients (really couch potatoes)
should be checked for
diabetes;
Kaiser does not think that is
necessary.
C. the national standard is some nine OB
visits in
a pregnancy; Kaiser believes that can be done with six visits;
D.
and this is the
tone of the many documents presented as outpatient or inpatient
science.
8.
Kaiser, according to the Recovery Plan, would also develop a massive IT
(information technology) effort such that there
would be pop-ups in front
of
each physician telling him or her what to do;
9.
This IT is described as costing $3 billion, although $1 billion was
wasted on the IBM CIS program highlighted as the state of
the art in Colorado;
A.
as much of the
system is simply imported from Wisconsin through the EPIC company, the
cost is inflated by adding in the time
needed to train all
Kaiser staff;
B. the figure was to be over 10 years,
so the
yearly
cost was not so huge;
C. the number looks large
enough to
steer anyone away from the idea that profits were being made each
year;
D.
EPIC
trainers from Wisconsin recall going into Colorado and having to almost
start from scratch; about the same time
Kaiser was testifying in
Washington that it had all but conquered IT problems and the Electronic
Medical Record from all its experience
back to the 1968 years of
Multiphase Testing.
10.
Meanwhile, with knowledge so codified, physicians could move away from
patients as coaches and convince the same
patients that
they had more
access through the care "teams" taking their places; patients
experienced more contact though
not understanding that it was less
expertise, e. g. a pharmacist whose goal was to talk the patient out of
Prilosec and back to the weaker Zantac.
11.
Kaiser
agreed to go into more venture projects partnering with Permanente at
the 50:50 level once again; often the trick was
to pour Kaiser IT at a
value of $14 million into a business like Caretouch and then spin it
off with Dr. Lawrence "still on
board";
12. The
profit
split of 50:50 as well as the presence of the physicians in the
boardrooms as decisions were made – really simply
rubber
stamped made sure the Kaiser executives and the Permanente physicians
were partners at every level – one for all
and all for one.
13.
The new plan included taxing the Kansas City and North Carolina Kaiser
units to prop up the Washington, DC showcase
unit and then close the
former two as not viable; excellent materials on this show up in the
Johnson County Courthouse on
the Western side of Kansas City (see
materials on KaiserPapers.org (in Section 24);
14.
The Permanente Journal was also started as an improvement of a
newsletter in the Northwest. It is published in Oregon but
vetted in
Oakland – legally and medically. It is the national
communication system for the Kaiser physicians – with medical
articles featured on the
cover and then
cost saving measures filling
half of the interior. MUCH information can be obtained
from these
public magazines – now almost completing 10 years at 4
magazines per year. The nurses now get it since they
are care givers (Beyond
scope of diagnostic
practice.)
This all is referred to as the TAHOE TWO agreement because it
renegotiates the power of Permanente v. Kaiser, this time with a
stronger physician power role and the same 50% profit sharing;
Later Dr. Lawrence was actually further demoted in power as he made a
raid in Denver and grabbed all the IT equipment and staff to
centralize IT; the physicians had no warning and it reminded them of
the Kaiser Sr. tactics before.
Section 5
– THE PERMANENTE PHYSICIANS
– ONLY A " PERCENT PROFIT"
For a while I, Dr. Phillips, was stumped by the Permanente statement to
Medicare in 1984 that they only made "5% profit" against my
calculations that the profits were as much as a doubling of salary for
each senior partner physician. I finally figured it out –
Permanente represents half the KP budget (rather than the usual 20% of
most systems). Permanente pays for clinic leasing, lots of the
personnel, and the physicians. A 5% profit of the whole Permanente cost
center of 50% allows for doubling of the physician partner income.
In 2005, Kaiser is trying to create an 8% organizational profit
("excess income") of $2 billion against the total of $25 billion
budget. Early results will be announced in February of 2006 to kick off
the bond market auction in New York (and organize the profit split to
Permanente), and final results to be posted on 990 tax forms in
November 2006]. Half of the budget involves Permanente and so does half
of the profit.
So a
$1 billion profit will go to
Permanente who I estimate to have 3000 of the 10,000 physicians as
partners. If $100 million is used to give bonuses to nurses, techs,
union bosses, etc. there would still be $900,000,000 to split among
3000 partners $300,000 each (a doubling of their base salary). Yet
Permanente could say to Medicare then and now – that we
(Permanente) only make a "5% profit," so what is the harm? After all,
you require us to include physicians as part of the risk. But then the
Plan and occasionally the Kaiser Family picks up physician shortfalls
by the IRS settlement,
Permanente is really not ever at serious risk.
Other ideas to be added to this section:
1.
The progression of leadership – Sidney Garfield, MD
…. "Robbie" Pearl, MD, and Francis "Jay" Crosson, MD; on the
radio Dr. Pearl in 2004 guaranteed that the
average care in Kaiser was
like that given to his own family;
2.
"… the individual physician was the profit center" (Smillie
76);
3.
"Physicians who created more than their share of unnecessary expenses
through the poor quality of their treatment were
encouraged to leave
the Medical Group (Smillie 177) [this is really about physicians who
give out the right care are managed
care unsuitable];
4.
Outside expenses hurt the profit line, so if they stay with urban areas
and get at least 50,000 patients from startup buy-outs,
then almost all
specialty referrals can be internal – two layers of gate
keeping;
5.
The physicians get benchmarking materials in the mail with each check
(every two weeks) that shows where they stand as a
business unit, e.g.
pharmacy utilization;
6. Physicians have 15 minutes
for most all visits, although the number is rarely published;
7.
Test interpretation should not include words like borderline
– it’s either clearly positive or negative; (this
deprives patients of information)
8.
Physicians can receive "Talking Points" quickly so that they can write
‘Letters to the Editor’ whenever there is a KP
brand embarrassment;
9.
Physicians have the dues
paid by the Plan to join medical societies so that they can rise to the
top – one recent President of
the
California Medical Society was a Kaiser emergency physician; it helps
to have the voting power to
get him there;
10. The Medical Board of California
uses a disproportionate number of Kaiser experts to evaluate care; it
is likely that Kaiser
allows double dipping for this time spent
– a Kaiser administrative salary and a Medical Board payment;
11.
The physicians heading up IT have no problem bragging to Congress that
Kaiser has always been on the frontier if
Information Technology even
as Kaiser buys a brand new system EPIC and has to learn from scratch;
government does not go back and check
Kaiser;
12.
Those physicians with the best business record – supporting
Permanente more than patients – rise to the top; the message
back
down is that business comes first and every doctor is being
constantly audited for every decision;
13.
Many physicians explain to patients that they will get "in
trouble" for ordering MRIs and other needed tests; other
will say it is
better to wait until January and a new budget year, as
the budgets are loosest then;
14.
Physicians in deposition or the courtroom are instructed to say that
they do not know what Kaiser Permanente really is –
thus
never
getting into the profit systems they all really understand;
15.
The Guidelines the physicians develop are not from science but from
profit motive, e. g. "do not test sedentary patients for
diabetes";
16.
As the Plan pays for malpractice defense and they beat most patients,
the physician can do just
about whatever he or she
wants; keeping the DNA Code
organism of Permanente healthy is the key to being a good partner.
Section
6 - KAISER’S CEOs SIDNEY, …, DAVID, AND GEORGE
For
a long time Mr. Kaiser was the external director and Dr. Garfield the
internal director of what was to become KP;
A.
In the beginning, Dr. Sydney Roy Garfield, was the CEO of Kaiser and
that continued for a long time. Mr. Henry Kaiser, Sr. had
equal
control, though, as he had to cosign the Bank of America loans
needed to build clinics and hospitals. They split profits
50:50.
B.
As the war ended in 1945 and the suddenly smaller organization decided
to go public, Eugene Trefethen – a close
confidant of Mr. Kaiser
– was asked to run the Permanente Health
Plan, a non-profit trust; but Dr Garfield really operated the
medical groups, the Health
Plan "as a single organizational
unit." (Smillie book page 62);
C.
From 1945 - 1948 the board rarely met. "The actual management of the
health plan might be envisioned as a circle
with Sidney
Garfield at the center." (Smillie
– p.65);
D.
In 1948 Dr. Garfield had to separate from the Permanente doctors for
tax reasons; but still had major control as plan and hospitals
chief:
E.
Mr. Kaiser and Dr. Garfield finally agreed that Dr. Clifford Keen
should head the program starting in January of 1954; the
Permanente
physicians were skeptical;
F.
Dr. Keene developed a Kaiser Foundation Research Institute at the
Richmond Hospital because he felt it would felt "respectability"
for the Kaiser organization would be
gained (Smillie p. 129); [Kaiser is now the largest nonacademic
"research" unit in the United
States with lots of CDC money pouring
in.]; (it's hospital libraries are some of the worst.)
G.
Meanwhile, Henry Kaiser kept calling each of the new hospitals
"My Baby" suggesting he still thought he was
running
the show as the Boss;
H.
When Henry Kaiser told a subcommittee of Congress that the physicians
are entirely independent of lay or corporate control, the
Permanente
physicians wrote back to Congress to correct the error; [this issue
plays out to this day – as Kaiser ads try to make the
physicians
look as if unimpeded in their decisions, the opposite being true];
H.
For a number of years Edgar Kaiser was president of the Kaiser
Foundation and Hospitals – that would have matched his
meeting with Mr. Ehrlichman in the White
House (See introduction); he retired in 1980 and died in 1981;
I.
James A. Vohs replaced Edgar Kaiser in 1980;
J.
Dr. Lawrence
was CEO for about 10 years – bringing in FNPs to do MD work:
1.
He went to Amherst College [so we shared the same campus and
premed
program one year apart]; then on to Medical
School at the
University of Kentucky;
2.
He interned in Kentucky;
3.
It is not clear if he
had direct patient care after internship, although there was a Peace
Corps stint which landed him back in
Washington, DC;
4.
Then he did his residency in Public Health at Johns Hopkins
University;
5.
He finished his residency out at the
University
of Washington in the State of Washington;
6.
There
he became
involved in the fairly new concept that part of what physicians do
could be done by a mid-level provider;
7.
This training cutting and cost cutting idea brought him some
fame; (The courses are for rural care, but most physicians stay in
the city.)
8.
He next became the Physician in Chief in a
Kaiser
unit in Portland Oregon. After that he was the PIC in Colorado;
9.
Finally, he was tapped to come to Oakland;
10.
There
he climbed up the ladder first as CEO, then President, and then
Chairman of the Board – finally all three, then, at the
same
time
(as he achieved increasing power);
11.
In his final year, where he was paid full salary to tutor Mr.
Halvorson, he clearly was not needed;
12.
Instead, he secluded himself in Oregon and wrote a book trying to
validate Kaiser’s team approach to Asthma (to counter
the
claim in
the movie "As Good As It Gets" through actress Helen Hunt that HMOs
don’t give good care to childhood
asthmatics –
movie
audiences clapped
around the country in agreement).
13.
Dr. David McKinnon Lawrence, then, with minimal direct
patient care
experience,headed up KP; he made the following
imprint:
A.
That from 1992-1996 he could solve most of Kaiser’s problems
through lots of contracting at the top and being
business tough at
the front line;
B.
That he could help Kaiser by being involved in tours with advance
teams that played up his being a member of the
National Academy of
Science [for what?];
C.
That he could castigate the Dr. Welby type of physician as an eagle
soaring over the canyons of the past, irrelevant to
today; that as a
physician he could represent both sides of KP;
14.
But the Balanced Budget Act of 1996 brought Kaiser like the rest of
managed care to budget losses; the physicians were
unhappy with the
relationships and pushed for more power (Tahoe II);
15.
Suddenly, Dr. Lawrence was pictured among a group of Permanente
physicians to give proof that he was now demoted
and equal to them. (See
elsewhere Tahoe II to see all of the changes made;)
16.
Suddenly he was in charge of the increasingly tough-on-patients "Path
to Recovery 2001;"
17.
Although this succeeded
(profits
returned), Permanente believes it was due to their taking a stronger
role;
18.
Finally, Dr. Lawrence lost power after removing from Colorado Kaiser in
Denver their mainframe computer without telling
the
docs first;
19.
Permanente was resolved to have a nonphysician as the next CEO.
(probably forever after);
20.
Dr. Lawrence vowed to stay out of medicine in his retirement but has
been working with England on importing Kaiser’s
tough rules
that keep patients out of hospitals or move them through
double
fast;
21.
Mr. George
Halvorson from Minnesota became the next CEO. He was then running
an HMO of about 1,000,000
subscribers but had
been considered successful (keeping costs low) and a national
player
with the Association of Health
Plans. His actions
so far:
A)
he made it clear that he did not need much tutoring from Dr.
Lawrence, the latter becoming redundant for his last year;
B)
he changed Kaiser from the IBM/CIS program in Denver to the
Wisconsin EPIC program developed in Kaiser
in Oregon;
C)
this was done because it was easier to partner with EPIC (end up on
both sides of the table) and EPIC was better for
patient billing
than IBM;
D)
he thus tossed out a $1 billion IT
effort that will still be kept as part of the $3 billion cost of EMR
(electronic medical records);
E)
EPIC stands for embedded pop-ups, and Kaiser achieved its goal of
having pop-up suggestions on every front line
computer so
Oakland could run the care of all 8 million patients;
F)
This is consistent with the "Permanente Patient Relationship" we will
find within the Permanente Map (Section 12); as
the
corporate practice of medicine is inconsistent with the Hippocratic
style of personal physician advocacy for the
patient, it is illegal
in all states;
G)
The pop-ups force every Kaiser physician to "do the right thing"
or lose time trying to ex- plain why not, the latter not
a
choice as it would trigger inefficiency and be degraded at the next,
secret partners meeting;
H)
The pop-ups had been developed by a joint study of Kaiser and the
Oregon Health Science University using Kaiser
partner
physicians to see how they could be gradually molded to accept this
approach.
I)
Mr. Halvorson has decided – differently from Dr. Lawrence
– that
long term power will come from truly giving Dr. Jay
Crosson 51%
of the power (thus to the Permanente Federation);
J)
He also decided that Kaiser’s charity monies should feed
back into the organizational goals of the HMO and thus be
used for
developing secret guidelines, lobbying in Sacramento and
Washington, DC, as a "public education" effort,
funding the train ing
of physicians who may well be recruited for Kaiser,
etc.; [the IRS hasn’t looked carefully at
Kaiser for decades];
22)
As with Dr. Lawrence, Mr. Halvorson’s salary each year (of
over a million dollars) can be expected to be doubled with
bonuses as the profits role in; he can be rewarded as the CEO
of
the Plan and then as the CEO of the Hospitals;
23)
And, thus, as part of Tahoe Two, Mr. Halvorson and Dr.
Crosson have co-chair-spots on the top executive
committee with Dr. Crosson being more
senior and in charge; yet HMOs
like to take the heat as Bad Cops so the physicians can come up
looking
like the Good Cops.
Section
7 - THE
KAISER PLAN
AND HOSPITALS using the same BOARD, CEO, PRESIDENT,
CHAIRMAN OF HE
BOARD, PRESIDENT, CHAIRMAN OF THE BOARD, TOP EXECUTIVE COMMITTEE, TAX
ACCOUNTANT, AUDIT FIRM, LEGAL TEAM, ADVERTISING, ETC.
1)
As discussed under the history of the various units of Kaiser, Dr.
Sydney Garfield was the "Founder" and Mr. Henry Kaiser,
Sr. was the "Boss";
2)
Dr. Garfield ran all parts of the internal operation including the
plan and the hospitals and employing the physicians under his
name
Garfield and Associates;
3)
While there were, apparently, Boards, they met very seldom; Sydney
and Henry made the decisions; any arguments between
the two
during the day could be settled in the evening as they had cocktails
with their wives – sisters: "On various occasions,"
Clifford Keene remembers, "I saw Mr. Kaiser take
on Sidney in the most
humiliating circumstances. If a man had
spoken to me like that I’d
want to fight with him
physically. It was most demeaning and I felt sorry for Sidney. Then
I guess after Mr. Kaiser
cooled down, he would have feelings of
remorse. Always there was the awareness of that family
relationship, the
Kaiser-Garfield cocktail hour, the two women
and Henry and Sidney." (Smillie Book 138 – Bancroft Library
Collection –
Bancroft Oral History - page 54)
4)
"In 1952, the Health Plan and Hospitals formally adopted
the name Kaiser, further testimony to Henry J. Kaiser’
growing
identification
with and involvement in the program. From that time
onward, the program encompassed the Kaiser Foundation,
the Kaiser
Foundation Health Plan,a nonprofit corporation, and the
Kaiser Foundation Hospitals, a charitable trust." (Smillie
book p.115)
5)
The word
"permanente" had come from the Permanente Creek in Los
Altos that never runs dry where Henry Kaiser made
cement.
6)
"The Permanente Medical Group, however, refused to change its
name" so that they would not look like employees of Henry
Kaiser. (Smillie p. 116)
7)
Garfield wanted the doctors to be called Kaiser doctors and lost. Henry
Kaiser, Sr. wanted the physicians to break into
three
groups to weaken them – that did not work either.
8)
The boards have identical members; thus Kaiser Plan and Kaiser
Hospitals are simply alter-egos of each other and in no
way
independent;
9)
This was an technique to make each tax exempt
in the eyes of the IRS; but the Plan can pass half its profits on
to the
Physicians and the other
half to the Hospitals and come out
being "non-profit."
10)
The Hospitals do not fulfill their obligations to charity but now under
Halvorson direct more such money to lobbyists, secret
physician guidelines, future Kaiser
physicians in residency, etc.
11)
No one can contact the Boards except by going through
Crosson/Halvorson;
12)
One Kaiser family – Henry Mead Kaiser
(See Section 48) - was disgraced in 2004 by borrowing $2 million
to try to make himself look like an
investor guru
in Europe – A Sacramento Court ruled he was to spend a year
and
one day in prison;
13)
A Mr. Tyson moved from the Board to being in charge of brand image, his
salary and bonuses jumped to $800,000 per
year (just
to try to sell Kaiser as a medical program rather than a mean machine
business); {After the 2006 renal transplant
scandal, a new brand image person was hired but Tyson is
still
part of the team};
14)
The Boards redirect discretionary money back to themselves;
15)
The Boards make interesting loans to executives;
16)
The Kaiser [national] Foundation Health Plan is the "Sole Member"
of each of its state’s plan (see 990 Form budget
summary)
–
thus it all happens in Oakland!!!!!
Section
8. THE ADVERTISING PROMISES (general)
This
is a good
starting point for a Kaiser investigation begins with the advertising
machine to define the promises:
1. Standard KP
health care level achieved now is supposed to be "superior care" (as
announced just inside the cover in
every Permanente Journal
since 1997 and also mentioned in MD recruiting ads); "superior care"
would be way above the legal
minimum of "prudent care" which comes up in medical
malpractice ("medmal") cases and medical board
inquiry;
2.
This is supposedly accomplished by physicians
coming to Kaiser from the best medical schools and training
programs who
communicate well and rapidly; [sug gestion - to match
that claim against any list of Kaiser physicians with the back
grounds
of the physicians displayed in the AMA Doctor
Finder site – and top medical schools are relatively rare];
3. Kaiser doctors
are supposedly allowed and encouraged to be just physicians according
to the ads [suggesting classic
Hippocratic oath advocacy of the
patient] through the absence of accountant pressures; see also new
Thrive radio ad –
"let physicians be physicians" heard in the
Fall of 2005;
4. Tag lines are
developed in Kaiser at Oakland after focus groups around the country
are asked to define what they want in medical
care, e.g. caring
physicians who know them well and will advocate for them; Kaiser has
published such materials in a variety of settings
–
The Permanente Journal, the internal Thrive ad
campaign discussions, etc.
5.
[Note
Kaiser’s lost the ability to use the "tag line" "in
the hands of doctors" after a successful, plaintiff legal
suit Olsen v.
Kaiser – two
patients who died; although the
settlement was buried from public viewing, the conclusion to ban
this tag line was clear.]
Check out: The Founndation for
Taxpayer and Consumer Rights (FTCR). The 2005 Kaiser "Thrive"ads
say
about the same – "let physicians be physicians" [with no
external pressure], again a fraud.
6.
As physicians seem to like the illusion of spontaneous, group
discussions, Kaiser internally explains that it practices group
discussions
before they occur and
even plants questions (described in the Permanente Journal) to make the
comments appear as physician convergence of
thought, for
example, that moving the physician back to a coach of a team is
okay;
7.
There is also
a KP "Brand Alert"
committee that responds quickly to any negative publicity,
e.g. missing the Anthrax
diagnosis in Maryland, the sexual
misbehavior
of a Kaiser Physician in Gilroy, probably the pedophile Kaiser
physician who masturbated all of the
male child
diabetics (Dr.
Peter Fischer/Kaiser Bellflower/Downey), etc.
Section
9 –
KP FIRST TAGLINE
– PERMANENTE MEDICINE (RATHER THAN HMO)
Although
HMOs enjoyed easy enrollments in the 1970s, the public caught on
that they were rationing machines and began to dis-enroll in the
1990s. In 1998 the enrollment number of Kaiser was 9.1 million; in 2005
after huge advertising it is less than 9 million. The
solution ad wise is to try to escape the HMO label and build the
Permanente Medicine label. The Kaiser Family Foundation was
allowed to reflect the public’s increasing disdain of HMOs
since Kaiser thought they could escape the connection
with
Permanente Medicine. So the physicians are pushed forward in
ads and made to seem caring and unrestricted. Meanwhile the
physicians who last are all clear about being profit centers
and viewing the patients as business units – "external
customers." Even staff are only "internal customers."
And they are encouraged in business memos posted on bulletin boards
in staff break rooms to view Kaiser as a"mean fighting
machine."
The HMO is supposed to take all the hits and
say that they are only trying to keep costs down to let more of the
uninsured participate. The physicians are supposed to float upward
into the ethical zone as a caring group trying to help patients
"Thrive."
As most enrollments occur in November,
the intensity of ads goes up then. One can only expect ads that
reflect focus group dreams and not reality.
Section
10 –
SECOND TAGLINE "NOT-FORPROFIT"
The
"Non-profit" [or "not-for-profit" ] phrase is
Kaiser’s second most important [though untrue] advertising KP
"tag
line" trying to set Kaiser apart from Blue Cross, PacifiCare,
Humana, and others. Several years ago CalPERS – a huge source
of California employees and retirees – decided only to work
with
the "nonprofits"like Kaiser and Blue Shield.
There was no indication that CalPERS ever understood if these two
systems were also for profit. Kaiser’s mutual contracting
with
Permanente – now for some 60 years – makes KP one
entity. In
fact, it should be PK (Permanente Kaiser) according to who runs
the show. The guarantee of the absence of pressure is reflected
in the ad slogan that the "Kaiser Permanente … is a
‘not-for-profit’[sic] group practice prepayment
program
headquartered in Oakland, Calif." – see typical press release
of 9/2/05 as Kaiser gave a portion of its obligatory public service
money 75% - supposed to be for California - to
New Orleans "Kaiser Permanente Pledges Total of $3 Million to Hurricane
Relief."
1. The repeat
promise "non-profit" organization as reflected in a Kaiser
Permanente 2001-2002 report called a "Quality You
Can
Trust":
A.
"Today,
8.4
million Americans entrust their care to Kaiser Permanente, making us
the largest non-profit health care organization in the United
States" – signed off by George C. Halvorson (typed name and
signature) "Chairman and Chief Executive Officer" and David
M. Lawrence, MD (typed name and signature) "Chairman
Emeritus."The guarantee of "non-profit"comes right
from the top.
B. "Unlike most of our
competitors, we
have no
shareholders to satisfy with short-term strategies.
"[Middle of
same three page source – ignoring the fact
that the organization has some three thousand, physician partner -
"shareholders" that care about every dime.]
2.
In contrast to the above "non-profit" posture, there is
Kaise Permanente’s profit ("excess revenue" ) of $1.8 billion
in 2004;
half of that went to the Permanente
partners (shareholders) through the Tahoe One and Tahoe Two
agreements so
fundamental to the
"partnership" of K with P.
A.
This is a
profit split formula that goes back to the Depression when "Dad"
Bechtel and Henry Kaiser, Sr.
agreed on a 50:50
split of profits on
building projects – aqueducts, dams, ships, etc. –
because any
other
numbers would show disrespect of one of the partners to the
other;
B.
Source of Bechtel
story – book Henry J. Kaiser Western
Colossus –
page 33 in a quote from the August
1943 Fortune Magazine:"And
his usual condition for entering any proposition was a fifty-fifty
division. ‘Dad’
had no patience with fifty-one,
forty-nine
arrangements. He used to say, ‘No man with a sense of
self-respect
wants to be controlled on
that kind of percentage."
C.
Source of Tahoe One details – several books written by Kaiser
physicians – Dr. Smillie’s book and Dr.
Raymond M. Kay
Historical Review of the Southern California Permanente
Medical Group –
3. Its Role in the
Development of the Kaiser Permanente
Medical Care Program. Dr. Kay was clear:
A.
"Though the budget variance was not large, it had a significant
effect on the surplus to be divided between the
Medical Group
and the Hospital, and hence on the partners’ sharing of the
surplus." (p.9) –1954;
B.
The Retention Fund was developed so that the profit could be more even
year to year;
C.
When the physicians had losses in San Diego in 1966, "the Health Plan
agreed to isolate and absorb any such
losses."
(Page
12). [And we see this over and over where the physicians are not really
at risk – there is always
startup of loss coverage
by
either the Plan or the Kaiser Family];
D.
For tax purposes the Hospitals and physicians were separated in 1956
– but only on paper; in 2005 one finds
Dr. Crosson
and Mr. Halvorson working just doors apart on the same
E.
"Distributing profits among the partners was a very real form of
sharing. Our
business advisors thought that the
distribution of
profit should be
related to the administrative responsibilities of the physician.
However, we
believed
it should be equal for all partners and that
the professional and administrative
responsibility of
each partner
should be reflected in his salary." (page 35);
F.
To protect retirement profits from the IRS a paragraph was added to say
that the profits might not always come
to a physician
(p.55);
G.
The Medical Service Agreement of 1958 included the concept that the physicians
would
get 50% of the hospital net surplus. (page 92);
H.
The Kaiser Family Foundation helped in expansion to Ohio and Michigan
(page 104-105). [Note – the KFF always insists that
is in no way involved with KP; it also presents no history on
its website.]
I.
Nurses were trained to do physician tasks. (page 112)
J.
In 1960 Kaiser started trying to put arbitration into its contracts.
One of the groups refusing was Kaiser Steel.
(p.127)
K.
K. Early on Kaiser insisted that it compete with at least one other
plan for any business so that members would
not be "captive";
later this protection was disregarded – many have only Kaiser
as the choice;
L.
Bonuses can occur in two ways – first that Permanente can
operate
at less than the contract level (e.g. $65 per member per month a
few years ago) AND one half of the total KP "excess
revenue."
M.
The entire Tahoe Agreement is included as an appendix including:
"Any excess of
revenue over the aggregate of these base needs would be shared in by
the Medical Groups and the Hospitals on some negotiated percentage
basis." [That was later clarified to be 50:50 in 1955 (page 168
Smillie book), the old Dad Bechtal teaching to Mr. Henry Kaiser,
Sr.]
N.
[Note that Edgar Kaiser was a key player in KP (page 167) –
the
same person that went to Washington and explained to President
Nixon through Ehrlichman that the less you do the more money you make.]
4.
Then in 1984 Kaiser was paid by Medicare to
write in detail about its physician payment
system; it was clear in
booklet - printed about
all the physician systems that Kaiser
preplanned the
excess revenue
at each budget cycle;
5. Source of "Tahoe Two"
details – the Permanente Journal – as various
stories of who to get out of the
problem of two years without profit in
an organization with sixty years of profit;
part of the Recovery Plan
for 2001;
6 .[Dr. Paul Wallace used the term "Tahoe
II"
in his power point summary of Kaiser history to
emphasize its
importance. ]
7.
Internal Kaiser efforts – for example, detailed in Kaiser
Colorado
- to spin the message of
physician
profits into the story that all of the money is directed to the $3
billion IT program.
Section
11 –
THIRD TAGLINE – PHYSICIANS KNOW PATIENTS WELL
– "YOU CAN
DO IT, DANA"
The ads try to make it look like the
individual physician knows the patient even better than he or she
knows herself. This is the Dr. Welby model that Kaiser actually
scoffs at – a physician patient relationship that was not
valid
then or now.
Despite all the awards this program won for
accuracy and patient education, Kaiser wishes the TV series never
happened. Yet they can still pander to the model in ads.
In
reality, the Kaiser physicians have set up barriers to knowing patients
individually. The Kaiser physician is – since about 1998
- just a coach to the "team." Access is easier – which
patients want – but the physician is more distant. Phone
calls
are
made to patients by nurses to try to get them to feel cared for and
stay home. E-mails for every M.D. in 2007 have the same goal.
The feeling that Kaiser projects in reality is
cold and thoughtless with huge barriers for the patient. This
seems to have been the reason that Kaiser failed in several states in
New England, New York, North Carolina, Michigan, Texas, Kansas,
Nevada, and Utah. That number is about the same as the number of
states (really urban areas within the state) in which they are
currently in – Hawaii, California, Oregon, Colorado, Ohio,
Atlanta, and the Mid Atlantic region with Washington, DC in the
middle – Maryland, DC, Virginia, and West Virginia. In fact,
Kaiser
is 75% a California phenomenon and really only slightly
national.
Yet they try to look national in their general
press paragraph – the largest non-profit HMO in the country
with
many awards and 11,000 physicians. The awards are really ones where
they helped design the test and then worked toward the test not
toward patient care.
The worst example is where Kaiser tried
to look the best in cardiac care by talking the sickest patients out
of any care; in this way they took the hardest 25% of patients out of
the survey and came out on top. (I am sure Dr. Parker – who
headed
this study for the State – would not go to Kaiser if he had
chest
pain himself.)
Section
12 - THE PERMANENTE MAP –
BLUEPRINT OF PERMANENTE (THUS KAISER AS THE ENABLER)
This
is a visual, short history of Permanente (and thus Kaiser as well)
developed by and published by Kaiser in its Permanente Journal
[suggestion – it would be wise to print a copy of the
Permanente
Map off this same web site – KaiserPapers.org –
and then have it
in front of you while reviewing the next paragraphs of map touring]:
1. The map
appeared
in the Permanente
Journal in purposely faded form accompanied by an
article;
2. The
article
explained that the Permanente fleet
was powered by the "group ethic" as if "the wind"
into its sales; [the
"group ethic" is
actually the
Kaisereeze phrase for not spending patient premium monies so the
Permanente groups
can have maximum profits];
3.
A San Francisco advertising company had been hired to help
the
physicians visualize their corporate
history, current position,
and future onto one map;
4.
A good deal of time was spent by top Kaiser partner
physicians on
this map in Oakland according
to one Permanente Journal article;
5.
The map was then blown up four feet by six feet and used as a
key
visual to motivate and teach physicians (see
picture of blowup in
the same "Permanente Map" article);
6.
Physicians already aware through retreats of what key words
mean e.
g. "Lake Tahoe" which has never had a Kaiser
clinic
standing for Tahoe One – need little help in following
the game plan; Lake Tahoe stands for the 50-50 profit
split described
in sections (See Section #4 – Tahoe One and Tahoe Two topics).
7.
The map shows, for example, that transition from the
"DOCTOR-PATIENT
RELATIONSHIP" to the
"PERMANENTE–PATIENT
RELATIONSHIP, " the latter on the captains’ wheels (perhaps
reminding some of the Enron employee/
stockholder
relationship); this
is the corporate practice
of medicine the try to deny;
7.
The only pathway to success is to use the altered science
Kaiser
calls the "Current of Evidenced-Based
Medicine"; [this
is junk science meant to give the least care possible].
9.
The path to the goal is to follow this "Current of
Evidenced-Based Medicine" into the SEA OF
SUPERIOR CARE; that will
lead to KP PROMISE LAND;
10. [Note that just
as Permanente is made into a near being with its "genetic code" (see
next section). KP is turned
into a quasi-religious cult
with a fleet
of ships sailing toward
the "Promise Land". Such approaches create the psychological
impetus
for physicians to bend or even discard
earlier medical ethics, like the Hippocratic Oath.]
11.
The goal is silicon valley IT with software ventures with EPIC,
investment capital [New
York auction of KP bonds],
and a "Our SUSTAINABLE
FUTURE," the realization of the
huge retirement monies available to those that can stick
it out to
retirement and consider themselves Kaiser physicians for life.
The
Permanente
Map
is the map to retirement bliss for the physician and poor care for
the patient. Kaiser tries to keep this Map from being introduced in
any of its legal battles.
Section
13. "GENETIC
CODE" PERMANENTE AS A BEING
Permanente is described
as having a "Genetic Code" and DNA in the book by Dr. John
G. Smillie – Can
Physicians Manage the Quality and Costs of
Health
Care? – The Story of the Permanente Medical Group.
This
Permanente
"genetic code" is also mentioned in the Permanente Journal
in recent articles – so the concept lives in the "Permanente
culture." [Such animation may echo for some the attempt by the
Third Reich of the German society to substitute loyalty of physicians
to the living "Volk" for those with lives not worth living.
Learn more about this in the book “The Nazi
Doctors” – a
Faustian duality – how good physicians in large numbers could
become executioners.]
The
details of the Permanente
Culture are still emerging:
1.
"The culture
of The Permanente Medical Group had to be transmitted. Such
transmission is
always a challenge after
passing the first
pioneer
era. Thenew physician
associates coming into Permanente could not be expected immediately
to
understand the complex story of the group or the rules and
procedures the group
had evolved for its
survival."(Smillie book
page 203);
2. The task would
fall to the Executive Committee – like a council of
elders.[Religious
style teaching comes in once
again.];
3.
"Cecil
cutting developed a finely chiseled, factually rich, and
well-delivered set speech, such as that given to a
conference
of new Permanente physicians in December 1966 – which set for
the history, five part genetic code,
and future prospects of
the program." (Also page 203);
4.
This methodology tries to make KP or at least P – Permanente
a
living organism fully in need of resuscitation as the
competing
patient;
5.
The term "genetic code" is still part of the orientation of
new physicians. It is also mentioned in the Permanente Journal
on page 90 Spring Issue 2005.
6.
Dr. Kay once referred to Kaiser as the "cosmic struggle,"
again a quasi-religious tone; Hitlerthought
he was in a
cosmic struggle to restore the Fatherland.
Section
14 – OVEREXTENDING EVERYONE’S TRAINING
– JANITORS THROUGH
PHYSICIANS
One way to save money is to
have everyone
practice above his or her training. Kaiser has used this approach for
a long time.
1.
Janitors and
other housekeeping personnel were renamed "service partners"
and then told to answer
patient call button requests for help
in the
emergency room; the
state of California caught this and told Kaiser to quit it;
2.
Nurses (RN only) are called practitioners with no formal
training and allowed
to do sigmoidoscopies, to change insulin doses, to
run cholesterol
clinics, to see
patients in primary care (though having no diagnosis skills),
etc. (Rural, Primary Care)
3.
Family Nurse Practitioners with formal training are taken way
past
their training by being grouped as 3 FNPs and 1 orthopedist to
cover 25,000 patients; the
FNP ends up trying to explain MRIs
to patients and to get surgical consents;
4.
Nurse
anesthetists in Hawaii Kaiser are asked to give independent
anesthesia without a
physician
supervision or backup;
5.
Nurse midwives are asked to do difficult deliveries beyond
their
training;
6.
Psychologists are asked to suggest medication changes to
psychiatrists hundreds of miles away, the latter with no chance
to see the patient;
7.
Kaiser internists in Colorado are taught by cardiologists to
do
stress tests with the outcome being a mix of accidental errors
and
purposeful under-reading;
8.
(2007 Update) - In Hawaii, primary doctors can be found
substituting for dermatologists and cardiologists {despite a federal
sanction and
probation.}
9.
General surgeons in the Los Angeles area were asked to do
pediatric
surgery – with
corrections
needed on some cases;
10. Neurologists
are asked to cover hospitals hundreds of miles away by phone with no
intention of seeing the patient the next day. All
of this saves money,
but it also dumbs down the ex- pertise of care and increases the chance
for error. But that was the way Dr.
Lawrence got his original fame
– by substituting mid level practitioners for physicians. The
idea was that a nurse with a four year
college degree and then a three
years masters program could almost match a physician with a four year
college degree, four years
of medical school, one year of internship,
and two to four more years of residency.
11.
The
death of the postman with anthrax near Washington, DC - after seeing a
Kaiser FNP and asking for an anthrax workup – is
just one of
tens of thousands of examples where this app-roach does not work.
Section
15 – "TEAM CARE" – PHYSICIAN AS COACH; PHARMACISTS
GIVE
OUT PRIMARY CARE (Quote in Ref. 24)
When Kaiser
learned that it was losing enrollees because access to physicians was
so difficult, the answer was not to hire more physicians but rather
to bring in the Team Care program. This can be seen at the top of a
typical mast in the Permanente Map fleet – and thus is now a
central theme. The physician coach would get special bonus money if
costs were reduced in this new strategy.
At the same time as Kaiser promised better acces, it encouraged several
doctors to quit. This meant more nurse diagnosing and fewer
experts.
The patient does experience more attention and more access but not more
care. One
of the pharmacist’s goals is to talk patients into cheaper
medications. In one case a pharmacist talked a patient out of
Priolosec three separate times, each time the patient got worse on
generic Zantac called ‘ranitidine’.
This is not
patient advocacy. This is Permanente profit advocacy – and
Permanente pays the pharmacist and decides who goes and who stays.
There has been no "evidence" that team care has a better
outcome. And in many ways it has been unpopular as it was predicted to
be. In discussiongroups recorded in the Permanente Journal
before starting this program, that it was really not necessary that
the patients like it.
Don
Parsons:
"We’ve
talked a lot about the importance of the
physician-patient
relationship and being an advocate for the patient;
yet,
we’ve been designing adult primary care
models based on
collaborative care teams where physicians may not
in fact
have a lot of contact with many of their patients."
-
Source The Permanente Journal Winter 2000 / Volume 4 No. 1Article
"The Permanente Medicine Roundtable: Defining our Practice
Principles" Kaiser physicians talking p.47.
Skip to
further in the article.
Jed
Weissberg:
"So
maybe
we should be talking about the Permanente-patient
experience,
which encompasses the broader relationship between
patients
and the medical group, which ideally acts as a kind
of
extended care team."
This ends up on the Permanente
Map (Section 12) captain’s wheel near the end of the water
journey
as the new relationship – the "Permanente-patient
relationship" - except that it is between a for profit
corporation who has taken no oath to be on the side of the patient.
And, in fact, on the same map, the physician-patient relationship is
simply an early part of the water path that the Permanente fleet
sails past.
The Kaiser ads, though, paint the physician as
being close to patients – which is back to the Marcus Welby
TV
show image that patients want. So the ads are only playing to focus
group wishes, not reality.[When I worked in a Kaiser ER, my boss
laughed that the ad the night before about a caring Kaiser
pediatrician in the Fresno area was a hoax; that physician worked far
away and has had a full practice for a long time. Deceiving patients
was apparently funny to this Permanente partner, one who said that his
own personal net worth had gone up $125,000
since finishing residency.]
Section
16 – PHYSICIAN RECRUITING - RAGS TO RICHES
One pattern that comes up often in Kaiser is the recruitment pattern
that might be called rags to riches. A physician grows up
in relative poverty in a South Asia culture – India,
Thailand, Figi’s families from India, etc. He or she looks to
hospitals
that will take foreign physicians. Often this includes the urban
New York City hospitals.
Kaiser then recruits in these
hospitals for positions out in supposedly sunny California. For
example, as Kaiser tried to give the East Coast anthrax information, it
included a view of the San Francisco Bay Area – close to Dr.
Lawrence’s million dollar view from Piedmont - as a
recruitment tease to encourage the same physicians to get out of
the East Coast.
Kaiser knows that it is easier to Kaiserize physicians to the
"Permanente Culture" of the "dual
responsibility" to patient and PERMANENTE if they have come from
a religion that is more life negating than Christianity. The
gradation of world religions according to life negating and life
affirming was done by MD and multi-Ph. D. Albert Schweitzer in
one of his many books.
Kaiser also
talks about how to recruit the physician in conversations in another
article in the Permanente Journal. The conversations are to focus on
absence of billing concerns, awards won, easy consultation, time
off, etc. There is to be no mention of the rationing of care. [Managed
care likes to call this the "rationalization" of
care.]
Once the new physicians arrive, they go on a retreat to hear about the
Permanente Culture from the senior partners.
While they learn that they will be audited from morning to night
against business efficiency, they also learn about the secret riches
that will be theirs if they can stick it out. The first goal over
the necessary first two years is to prove that they are "managed
care" compatible – correct balance of business over patient.
Then they can start up the partnership ladder making more each
year.
Finally, they can become senior partners with a
near doubling of salary as money gets squirreled away for golden
retirements. Internally the physicians often told me, (Dr. Phillips)
"I’m
not really a Kaiser type, I’m just waiting to vest," to
create some level of steady income after retirement. Actually
the work load goes down as one gets more senior – the goal
then being to watch the hourly " pool" (fire at will) doctors and the
partner want-to-be-is working the harder
shifts.
Those physicians that do the full and correct job at
Kaiser must stay hours late for the volume of work presented. I tip
my hat to them. They describe themselves as "Kaiser slaves,"
giving real medicine at unreal hours. One physician I knew did this
just to get benefits to his handicapped daughter; he would be
among those that would be needed to rebuild an ethical system should
Kaiser implode in ethics scandals.
Section
17 – MEDICAL MALPRACTICE COVERED BY THE PLAN (Reference 52)
One
of the outcomes of the Tahoe One restructuring was that the Kaiser
non-profit Plan would be responsible for all costs of any malpractice
action against any of the Kaiser (Permanente) physicians, that would
include the senior partners of this for profit corporation. That
means that the Kaiser Plan is a quasi-charity uses patient premium
monies to fight against allegedly injured Kaiser patients.
This is all
codified in the Medical Service Agreement (for full draft - see the
KaiserPapers.org) of each Permanente unit with each Kaiser Plan
unit. [The profit split is also part of the agreement but an
attachment (Article K – Section 24) that is kept highly
secret
from the rest of the world.] The physicians, in turn, have to agree
that they will let the Plan make all the legal settlement decisions.
They are also to be considered Kaiser physicians for life –
and
can get their retirement monies only if they cooperate with
Kaiser’s defense strategies long after they have retired.
After
leaving Kaiser and then being called back to be deposed in all legal
action or testify in court, the physicians will also be paid their
past salary - $100 - $130 and hour for each hour spent. [The
physicians must opt for Kaiser Care in retirement - it is called
"scary" in a Kaiser Permanente doctors newsletter in
Denver.]
Next, the physicians can be protected by chart tampering. First
the chart comes to the participating physician (who might have
committed the error) on the grounds that he or she can withhold
any material that might be psychiatrically revealing or damaging. This
is a big invitation to alter the chart in many ways. Tampering includes
altering entries (now mostly electronic), deleting pages or whole
sections, scrambling the chart, copying it
so it won’t show up well or key signatures will end up
missing, adding other patient’s charts, etc. The goal is to
make the expert review to complex for patients to afford the hourly
time of the
expert physician.
One example of
tampering is when a female necklace appeared on a shoulder x-ray on a
male patient who has never had a necklace. Another is to have
biopsy slides disappear. One had notes with "AMENDED" written
twice. There are endless variations. Kaiser will
also pretend that it cannot find one of its physicians even if he
is working across the San Francisco Bay at another Kaiser, e. g. ENT
case with destroyed accessory nerve function and right shoulder
girdle paralysis for life.
Next, the chart goes to the Kaiser
legal team. The methods of tampering include removing material,
wrong patient material, copying too small, rearranging pages,
lack of pagination forcing cut and paste to reassemble, copying light,
copying so signatures and training won’t show up (nurses
making insulin decisions), etc. They legal team keeps a good
copy and creates a bad copy as well to be given to the
patient’s
family or their attorney.
Often the Kaiser attorneys will
give a small portion to the patient’s family or attorney. In
one
case in Southern California they blamed the patient for not getting his
full records; the same Kaiser attorney said that Kaiser never
disturbs records.
[I,
Dr.
Phillips, have never seen a Kaiser chart in a medical malpractice
forum that has not been tampered]
Perhaps a
decade ago, the California Supreme Court castigated Kaiser for its
unfair malpractice, arbitration system. Kaiser had stalled a legal
case to let the patient die of his illness. This was the case
Engalla v. Kaiser – see the HARP.org web site for this and
other
selections.
The "Blue Ribbon Committee" (needed to
reform Kaiser under court order) chosen by CEO Dr. Lawrence –
with
a few judges on board but still Kaiser empathetic recomended inside
the report that both the Kaiser attorney and the patient’s
attorney get the same records at the same time. The recommendation
was mysteriously dropped in the final version and has never been
followed!!! Little was done except to have an "independent"
legal office run the arbitration system at $1 million a year; the
head of this office then testified in Sacramento as to how well it
was working (consumer groups appropriately complained).
Add
in forced arbitration with judges who become dependent on Kaiser
income – an average of three $15,000 cases a year
supplementing
their retirement incomes – and the system provides absolute
power
back to the HMO. Absolute power leads to absolute corruption (an old
phrase restated by President Kennedy at Amherst College on the
dedication of the Robert Frost Library where I, Dr. Phillips, was
simply a premed usher). Kaiser does not mind violating the ethic of
talking to the judges on the side as well – see San Diego
arbitration case that Kaiser by craft alone won (see also Section 38
– baby dies).
Whenever possible Kaiser will prevail in
arbitration over injured patients or families by using legal
technicalities. An Oakland father was delayed in getting an expert to
testify on a case of poor delivery techniques with his son dying
at home 16 days after birth and on a respirator. He is appealing but
with little chance of being heard. Judges that have Kaiser as their
Health Plan get good treatment and assume it is the same for everyone
else. Auditors might look for blue stars on the front of special
charts – no need for appointments, etc.
Section
18 – Government as Kaiser’s Rich Uncle;
In the book, Mr. Kaiser Goes to Washington, the author spells out
a new type of businessman – who is a "governmental
entrepreneur." The goal is to look for business opportunities
within government. Kaiser and Bechtel – working as partners -
learned how to benefit first from the New Deal and then the War by
solving FDR’s problems. Ross Perot became rich working out
Medicare health billing audits. [Halliburton has become good at this
now
probably with same formula of 50% profit to each level
of subcontractor.] When Mr. Kaiser was asked to show off his ship
building prowess in the Richmond area of California, he
answered that the real tour should begin in Washington where it was all
set up.
Mr. Kaiser was able to pull off many advantages
for Kaiser Permanente (under its former names) by his relationship to
government. Dr. Garfield had been recruited to the war but then
was allowed to get out of the war to set up private health care in
the West Coast shipyards. Kaiser was given almost free clinics from
the government after the war.
When there were price freezes, Kaiser physicians were allowed to escape
that problem.
"Wage and price controls, imposed by President Nixon in 1971,
created a problem until Kaiser-Permanente negotiated a satisfactory
outcome by obtaining an agreement that the Health Plan was not
considered an ‘insurer,’ nor were the doctors
considered
‘providers.’ Both were combined as ‘an
institutional provider."
(Source Smillie book – on page number 238)
Then the HMO Act
of 1973 was built around Kaiser’s model – giving it
a huge
advantage. All units became federally qualified HMOs – with
more
"startup monies." (See Nixon speech.) All Kaiser units are
Federal HMO.
Employers were required to have
one open model HMO and one staff model HMO for all employees
–
whether or not the employers thought these had quality.
Later ERISA gave legal suit protection to all HMOs, suddenly
immune like diplomats. An AMA article called this the 13th year
–
1986 - ERISA addition a great new boost for the HMOs created in
1973.
The IRS used to challenge Kaiser physicians incomes but later the IRS
has given letters protecting them where the parties
are described as "X" and "Y" so few can see what
is happening (http://www.pro-adv.com/1-issues/4-98.htm
- "IRS Approves Dual Organization Deferred Compensation Plan.")
(These letters let the physician build up huge retirement monies
hidden under the plan until retirement. )
Kaiser succeeds
because of lots of help from its rich Uncle – Uncle Sam.
Section
19 – California Helps Kaiser Float $3 Billion in Bonds;
1.
The bonds are often called "Kaiser Permanente" bonds but in
fine print only obligate the Hospitals cash flow to repayment;
so calling them "Kaiser
Permanente" bonds is
another fraud of
its own this time involving New York banks.
2.
Kaiser Permanente is called "non-profit" in their booklet
which is mail fraud as these booklets are mailed around the country;
[mail fraud was the key solution in the book and
movie ‘The
Firm’ to putting a stop to a rich and ruthless group of
attorneys.]
3.
The docs are not touched if the bonds fail, nor their golden
retirements; so Permanente really has nothing to do with it but be
part of the label bait for seniors who
have $25,000 to buy in;
4.
The Fitch
company of New York rates Kaiser and allows the "non-profit"
myth of KP to come out with their ratings; they
are open to suit
in my opinion for this fraud and have been carefully warned in
writing (See letter on KaiserPapers.org);
5.
In the bond booklets – which are free – Kaiser
outlines all the
possible problems that may occur –fraud
rulings, IRS rulings, etc.; this is a
good place to look for
Kaiser’s vulnerabilities, which are many.
6.
Kaiser issues its previous year profit prediction in about February
of the next year in order to prepare for the New York City
auctions
that will take place in about March of each year.
In
California the Kaiser Plan loans Permanente money to donate to the
governor. A consumer
group caught this and complained. The
state was supposed to look into this after the complaint; silence
followed.
At
Kaiser
Christmas parties for local politicians,
TVs are often given out as special door prizes
(Hanford
California 2004). Kaiser can only exist if the government gives its
support or fails to regulate the HMO. The TV gift monies come from
patient premiums meant for health care.
Section
20 – Beltway Relationships – White House, Congress,
and Supreme
Court;
1.
"Bain and
Associates | Case Study – Kaiser Permanente" as a good place
to start on theInternet.http://www.bainpr.com/cs_kp.html
2.
Dr.
Nudelman’s background is a common crossover of people between
the White House and Kaiser. "Phillip Nudelman,
MBA, Ph. D., is
chairman and president of Kaiser/Group Health, a nonprofit
organization serving over one million people. Dr.
Nudelman is also
president of Group Health/Kaiser Permanente Community
Foundation, dedicated to improv ing the health of
communities in the
states of Washington and Oregon and in northern Idaho. The
foundation supports health education and
promotion,
research, and
high-quality care for these communities. Dr. Nudelman participated
in the White House Task Force for
Health
Care Reform and the
President’s Advisory Commission on Consumer Protection and
Quali ty
in the Health Care
Industry. He is
the current chair of
the American
Association of Health Plans, serves on the Pew Health Professions
Commission and on the board of
Premier, and is
co-chair of the
National Advisory Council on Professional and Organizational
Ethics."[Ethics indeed.]
3.
LOBBYISTS –
this activity is now funded from hospital required 3% "charity"
funds; " Don Parsons, MD is our Washington
lobbyist"
(Winter 1998 Permanente Journal – Later in the Summer 1998
journal
he describes Kaiser’s view of patient rights –
actually used to
stop the rights effort.)
4. Kaiser helped defeat the
Patient’s Bill of Rights by helping to launch the Medical
Error campaign (Source – USA Today); this
moved the focus
from rotten
barrels (HMOs) to frontline (mostly private) physicians –
supposed
rotten apples. Kaiser forgot to
mention that their wrong diagnoses
are the most dangerous source of patient care error in the US. But as
Kaiser physicians are
disproportionately California Medical Board
"expert witnesses," thepartner experts judge the partners –
a sweet deal.
5.
Kaiser likes to use its money losing Washington, D.C. unit to try to
impress Congress. And Permanente Journals are left around
legislative
offices to make Kaiser look like it is intellectual and
into research.
Section
21 – Agencies Help Kaiser – HHS, NAS, AHRC (the
"arc"),
and CDC;
1.
HHS
Years ago when
Kaiser was being magnified by the HMO Act of 1973, Health, Education,
and Welfare were all one NEW department. The term "HMO"
or Health Maintenance Organization was created in 1973 simply as a
way to promote the Act to the public and get it passed. Even
Kaiser admits this phrase creation in Summer 2004 Permanente Journal
page 41 – in a discussion about Kaiser slipping back to fee
for
service by charging co-pays.
Now Education is separate from Health and Welfare. The
newest name is Health and Human Services whose organizational chart
can be found easily on the Web. Kaiser interacts with many of its
units. Each year HHS and Kaiser negotiate HMO payments for care;
seniors make up 25% of Kaiser’s income even though they are
10%
of the patients.
2.
CDC
The CDC is often in need of testing immunizations. Kaiser considers its
8 million "external customers" [name for patients in business
model] fair game for testing with a minimum of research
subject protections. While it does, apparently, use an Institutional
Review Board for consents and research, there is no
indication that this is not just a rubber stamp activity.
Kaiser’s
level of ethics can be measured by their requiring employees ("internal
customers") to have immunizations by such
statements as "the State requires it," which is untrue. The
goal is to get as much CDC money flowing in as possible. Putting
ex-CDC leaders on the Kaiser Board is another way to do this. Board
members in the Bay Area get about $50,000 a year for little work. It is
all about networking with the CDC.
Kaiser’s lyme
disease testing is an example of misusing CDC criteria. The CDC has
strict testing requirements to include only the most obvious lyme
cases for disease tracking. But the CDC says that these tests will
miss many with the disease and do not represent full screening.
Kaiser uses the CDC screening test only and admits it will miss lyme
cases. This is another sad area that will be part of the
historic
legacy of Kaiser once it is transparent.
So there is a whole
area of greed in immunization testing. This is well developed on the
Website KaiserPapers.org.
C.
NATIONAL ACADEMY OF SCIENCES
(WAS)
For years many have thought the NAS was the pinnacle of science in the
US. This was supposed to be an untouchable
group of scientists who fed good science into the government. The first
problem to be seen is that foundations are adding
funding where the government is too frugal. Suddenly the Robert Johnson
Foundation is thanked for funding many programs in NAS; this is a
foundation set on trying to magnify the health care roles
of non-physicians – thus being a Kaiser ally.
Next thing we
know is that Dr. David McKinnon Lawrence is made a member without
contributing anything to science except the idea that medical care
should be diluted and given out by the less
trained.
Other Kaiser
management shows up there as well. Pretty soon the NAS spin-offs (1970)
– the Institute of Medicine (IOM) - is the one choosing
what America focuses on – individual physician error rather
than
the ethics of managed care. Or more immunizations and less
critical care. Or the supposed disorganization of private
medicine.
Each
campaign [like Pogams of the Tzar in "Fiddler
on the Roof"] is heralded by a bound book and usually becomes the
rallying cry of the Joint Commission in Illinois as well. One
particular such book is Crossing the Quality Chasm published
by the IOM in 2001. It was published by the National Academy Press
in Washington, DC.
The author team was the Committee on
Quality of Health Care in America.
On this committee we find David McKinnon Lawrence, Chairman
and CEO Kaiser Foundation Health Plan, Inc. Oakland, CA. [Before
leaving he added Kaiser President title as well.] He is joined by many
of his managed care supporters/ "evidence" authors – Donald
M. Berwick, Boston entrepreneur, Lucian L.
Leape of Harvard Public Health, etc. Berwick is a favorite in
Kaiser articles as an independent commenter on Kaiser.
Donald Berwick chaired the subcommittee on "Building the
21st Century Health System"organ- ized somewhat like Kaiser. Mr.
Berwick helped to bring "evidence" information from England to Boston;
many have thought that this was just the
cheapest approaches as the studies were often done by the government
of England in the University of York.
Real
"evidence" guidelines – sponsored as the Cochrane
Collection after the accountant Archie Cochrane would be cost
neutral – more care in some areas and less care in others.
Support
for this book IOM "Chasm" book and study came from such groups as The
Robert Wood Johnson Foundation, the California
Health Care Foundation, etc. – both with strong ties to
managed
care.
That should be no surprise.
D.
AGENCY FOR QUALITY CARE AND RESEARCH – AQRC OR "ARC"
Some years ago this
group with a slightly different name was about to self-destruct. So it
re- invented itself and took on the above name, thereby
taking on the mission of measuring medical "quality"
all over the country. The budget of "ARC" is now some $300
million a year. Many university researchers under ARC contracts fight
for increased budgets every year.
One grouping of "research
money" goes to contracted EVIDENCE PRACTICE CENTERS – e.g.
Duke University a Kaiser "partner." Sometimes Kaiser gets
its experts for malpractice cases from these physicians who know Kaiser
can influence their research funds. Suddenly the care becomes excellent
in the eyes of these professors. A Duke expert
testifying in Colorado would look independent on the surface; the
injured patient is the loser.
Kaiser works very closely with
– even kicking in extra money – the Oregon Health
Science
EPC –another "partner." The head of this research program
is the only American on both the Canadian and the American "Working
Committee" on guidelines. She transferred
to Oregon from Duke University; Kaiser can be seen as outside the
process and still be inside. One of the researches of a Ph.D.
at Oregon Health Science involved seeing if Permanente partners could
live with EPIC pop ups, a useful corporate goal but not one that
should be funded by tax dollars. It turned out that they could
and their EPIC pop-ups are now the national Kaiser standard.
ARC
first spent some $500,000 to $1 million each on defining "evidence
based" care for key illnesses where government hoped to save
money. But three years later these were considered out of date,
and ARC had no way to improve them. So ARC gave up the role and
turned to managed care to
fund
the National Clearinghouse for protocols of care. This group in turns
licenses their material to
plans like Kaiser who re-mold them into cheaper recommendations
and make internal committees feel like they are doing the design.
Out of this comes cheapest pathways not science of medicine path-
ways.
One attempt ARC made was to see that two me bedical
journals – one for pediatricians and one
for
emergency
physicians – came out with the same article at the same time
– the best approach to fever in the child from 3 months to 24
months. That
was supposed to be
the
standard. Money was paid to both journals
for their-cooperation. Then Utah pediatricians found out that 95% of
Utah pediatricians did not agree with the guidelines – that
they had been developed by children’s hospitals with house
staff and did not fit the office setting. The guidelines died with no
plan for future resurrection. Yet
government will occasionally try to resurrect them to go after
individual medical licenses as if this useless doc- ument is
still a useful "standard of care" to impose on physicians
after a bad outcome.
Now there are so many different
guidelines floating around from each HMO system that most office
physicians often just file them in the wastebasket. All
integrity has been lost. It is like the mountain top snow has ended
up in the muddy and dirty delta of profit focuses. But at Kaiser
the end result is computer pop ups designed in Oakland and forced on
front line physicians from Maryland to Hawaii. Yet Kaiser
won’t
publish these for outside physicians specialists or generalists to
review. (See Section 31.)
Finally NIH Support
grants to
Kaiser
- In
the year 2000
"Kaiser Foundation Research Institute" in Oakland,
California received
$17,722,000 under "Non-profit”
Institutions. This should be audited in relationship to the profit
goals of Permanente who runs the program.
Section
22 – Shadow Government Agencies Help – The Forum,
G-7,
etc.;
The Forum - When I called once to learn
more about ARC, I was told that the real money was nearby in the
private organization called THE FORUM FOR QUALITY CARE run by Dr.
Kenneth Kizer formally of California. His background includes being
head of EMS for California, then head of the California Health Care
Foundation, then head of the VA, and finally over to the private
side of power as head of the Forum, his best salary yet by far.
He extols the great success of the VA in eliminating error –
which is false – as one of the reasons he can do the same
across the country. The last time I worked for the VA the lightbulb
was out over the medication cabinet, x-ray was using poor columnating
(leading to excess exposure of health tissues),
clinics were hard to access, etc. Even the attending staff –
mostly into publishing more than patients – had to be chided
for
not seeing the patients and allowing VA care to mean resident
care.
The Forum does not allow any citizen – even physician
– to join. Rather it is about organizations joining who then
pay dues according to size. At the time when the list of members
was public,
Kaiser
Permanente was there. Now the list is secret.
Generally, the Forum sets the agenda for ARC and is therefore a type
of shadow government. At least Henry Kaiser, Sr. was more open
about his activities in Washington.
G7
– Kaiser
would dearly love to have its electronic medical record become the
world standard and with secret partnership with EPIC – the
Wisconsin vendor – make back all the expense and more of
developing
this material. One way to do that is to work closely with other big
players. One will find Kaiser easily by opening up G7.
Section
23 – Bankruptcy Case of Dr. Moses – Protecting
Retirement
Riches;
see:https://kaiserpapers.com/businesspractices/moses.html
Some
years ago Kaiser orthopedist, Dr. Moses, went bankrupt. He was then and
thereafter a
Kaiser leader with many years of Permanente
partnership. His hope was to protect his retirement profits from the
bankruptcy trustee. Many documents can be found on the
KaiserPapers.org to get to the legal documents that developed in
Los Angeles, then Pasadena, and finally San Francisco for appeal.
Permanente came in and joined the case so as to defend not only the
secrecy of the amount but also the idea that creditors could ever
touch it.
The court papers reveal that Permanente admitted
that the money came from Dr. Moses being a partner of a for profit
corporation. The trustee noted that the agreed monthly payout for life
at retirement would make Dr. Moses a millionaire in this asset alone.
And he noted that Dr. Moses could choose to
retire within a year or so.
Permanente won the individual
argument since the money was not literally in Dr. Moses’
hands but
available only if he agreed to organizational goals at and after
retirement – like taking no other jobs after leaving without
Permanente permission. But the papers give insight into the various
extra monies that accrue above the typical yearly salary now of
$250,000 a year plus major benefits. The interested accountant
could develop the material someday into new insights of the money
flow in Kaiser.
Dr. and Mrs. Moses were found gulty
of State Tax Evasion.
Section
24 – Kaiser Physician Sues Kaiser as KP Leaves Kansas City;
Some
years before closing its Kansas operation, Kaiser Permanente bled it
down by forcing it to contribute $3 million a year to prop up its
Washington, D.C .unit. The latter was developed to try to make
Kaiser look national and be near Congress and the White House but
has been a losing proposition from the beginning.(Kaiser bought in
to Washington, DC as Humana left.) When Kaiser did close down its
Kansas City unit(and thus its presence in Kansas), the Permanente
physicians learned about the closure in the newspaper. This ticked
off one of the physicians – Dr. Waxman - who had been in
leadership. He sued Permanente first as part of a group of three and
then on his own. His request was that he become the auditor of the
flow of money as Permanente left. He was sure his practice
buildup time had a value.
He lost the case but contributed
enormously to our understanding of KP from the inside: (details
to be expanded in future enlargements of this investigation) Also in
the court papers is the Permanente meeting in which Dr. Jay Crosson,
President of the Permanente Federation, joined by videotape to try
to tell the physicians that the decisions were proper and further
appeal would not help. He specifically told them not to appeal the
financial decisions to the top executive committee, The Kaiser
Permanente National Partnership Committee, which he co-chairs with
CEO Mr. Halvorson.
Perhaps the most important document in the
Johnson County legal file is the Medical Service
Agreement
between the Kansas Permanente Group and the Kansas Health Plan
–
see KaiserPapers.org – "A Kaiser Permanente Medical Service
Agreement" j ust above "View the Selected Writings of Dr. Charles
Phillips." And within that is the usually secret
Article K to be found below in its entirety as eight pages –
the for profit split guarantee together with a "corridor; a method of
keeping the profits similar year to year."
ARTICLE
K
At Risk Compensation
Section K-1 Planned At Risk
Compensation
https://kaiserpapers.com/businesspractices/kpmsaK.html
Medical
Group is placed at risk with respect to a portion of its planned
compensation, called
Planned
At Risk Compensation. The amount of
Planned At Risk Compensation for each calendar
year
will be set
forth, or determined in the manner set forth, in the Memorandum of
Understanding.
The
reasons for placing Medical Group at risk with
respect to a portion of its planned compensation
are
to:
(a)
Provide Medical
Group with an economic interest in achieving optimum efficiency and
economy
in the
provision of Medical
Services, Hospital Services and
Administrative
Services incident to the conduct of the Medical Care Program,
consistent with maintaining
appropriate
standards of quality
and
services; and
(b)
Help protect the solvency of Health Plan by transferring a portion of
the financial risk of conducting the Medical Care
Program to
Medical Group; and
(c) Meet the requirement of the
Health
Maintenance Organization Act of 1973, as amended, and
regulations and rulings
thereunder, to
the extent that they
require Medical Group to be
placed financially at risk. Section
K-2 Calculation of At Risk Compensation
Planned At Risk
compensation will be adjusted as follows
to produce At risk
Compensation:
(a)
If there is zero
Net Program Revenue, Planned At Risk Compensation will not be
adjusted;
(b) If there is a deficit in Net Program
Revenue,
Planned At Risk Compensation will be reduced by an amount equal to
the lesser of
Planned At Risk
compensation or 50% of the deficit in
Net Program Revenue;
(c) If there is any Net Program
Revenue,
Planned At Risk compensation will be increased by an amount equal to
50% of Net Program Revenue,
except that
At Risk
Compensation
will not exceed 10% of Medical Services Costs for the year. If At
Risk Compensation (that would be payable were it not for said 10%
limitation) exceeds 10% of Medical Service Costs, then the excess
over 10% will be retained by Health Plan and utilized in furtherance
of general Medical Care Program objectives such as increasing
benefits to Members, adding to or improving facilities, or minimizing
rate increase requirements in future years.
Section
K-3 Determination of Net Program Revenue
The
sum of
the following amounts will be subtracted from Program Revenue:
(a)
All Health Plan
costs and expenses for the year (including the cost of wage, salary
and fringe
benefit
increases
for employees of Health Plan, but excluding the amount of such
increases to non-unionized employees not approved by Medical
Group), except that the cost of any qualified retirement plan is
the amount budgeted to fund the retirement plan trust ("Trust")
regardless of the amount computed pursuant to Statement of Financial
Accounting Standards No. 87, Employers' Accounting for Pensions
("FASB 87"), but excluding (i) depreciation, (ii) taxes and
other governmental impositions or charges, (iii) expenses, if any,
allocable to the production of Excluded Revenue, and (iv) actual
compensation to Health Plan and Hospitals management personnel
determined at year end, in addition to monthly salary, as recognition
for services performed during the year; plus
(b)
Base
Compensation to Medical Group for the year under Article J of this
Agreement; plus
(c)
Planned At Risk Compensation and
planned
compensation to Health Plan and Hospitals
management
personnel determined at year end, in
addition to monthly salary, as
recognition for services performed for the year; plus
(d)
Base
Compensation to Hospitals for the year under Article G of the
Hospital Service
Agreement,
except (i) amounts
allocable to
depreciation, and (ii) taxes and
other governmental impositions or charges; plus
(e)
Revenue attributable to Nonmember and Workers' Compensation Services;
plus
(f) Other Revenue; plus
(g) Miscellaneous
Revenue collected and retained by Hospitals (which reduces Base
Compensation
to Hospitals referred to in
(d) above; plus
(h)
The net amount,
if any, by which the aggregate sum of actual expenses is less than the
aggregate sum of planned expenses
(as set forth in the Operating
Budget) to the extent attributable to:
- Delays
in or early openings of new facilities; and
- Delays
in or early acquisition of facilities or sites for proposed facilities;
and
- Medical
Group extraordinary expenses generally
related to new facility startup costs; and
- (iv)
Any other item agreed to in writing by Health Plan and Medical Group;
plus
(i)
The amount
set forth in the Operating Budget and Memorandum of Understanding as
planned cash
generation to meet the
planned capital
requirements of Health Plan
and Hospitals,
(A)reduced
by the amount, if any, by which the amount budgeted to fund any
Health Plan or Hospitals Trust exceeds the
amount computed
pursuant to FASB 87, and
(B)
increased by the amount, if any, by which the amount budgeted to fund
any Medical Group Trust exceeds the amount
paid to Medical
Group for contribution to the Trust; plus
(j)
The planned amount of taxes and other governmental impositions or
charges upon or payable by Health Plan or Hospitals,
increased or
decreased by the actual amount of any variance from forecast in any
such tax, imposition or charge, but
excluding any increase or
decrease attributable to a variance due to a change in
organizational status or classification, change
in law,
administrative or judicial decision, or mistake of law; plus
(k)
Any other item agreed to in writing by Health Plan and Medical Group.
The
balance of
Program Revenue, if any, remaining after all of the foregoing have
been
deducted is Net Program Revenue.
Section
K-4. Payment of At Risk Compensation
At
Risk
Compensation will be determined on an annual basis and final payment
will be madewithin a reasonable time following
completion of
the
outside audit for the year, but in no event later than April 1 of
the following year. Health Plan will periodically estimate and report
to Medical Group the status of At Risk Compensation, and advances
against estimated At Risk Compensation may be paid at any
mutually
agreed time.
Section K-5 Distribution of At Risk
Compensation
At Risk Compensation will be paid to
Medical
Group, free from restriction, for distribution among employees of
Medical Group in such manner as Medical Group, in its discretion,
may determine. Medical Group intends to implement equitable
arrangements under which At Risk
Compensation will
be
distributed on an individual, department, subgroup, or
other appropriate basis so as to constitute an effective incentive
for efforts of individuals, departments and subgroups to further
the common interests of Health Plan and Medical Group in
providing maximum benefits to Members at the most reasonable cost
consistent with maintaining accepted professional standards of
Medical Services and Hospital Services.
Section
K-6
Determination of Net Medical Group Revenue
Net
Medical
Group Revenue is the amount, if any, by which the sum of:
(a)
Base Compensation to Medical Group; plus
(b) At risk
Compensation;
plus
(c) Revenue attributable to Nonmember and Workers'
Compensation Medical Services; plus
(d) Other Revenue; plus
(e)
Any other revenue agreed to in writing by
Health
Plan and
Medical Group as subject to this definition; exceeds all Medical
Group expenses
(including salaries of Physicians and any
Residual
Claim paid by Medical Group but not reimbursed by Health Plan, but
excluding any payments under Section K-4) incurred by Medical Group
during the calendar year relating to performing Medical Services and
other services under this Agreement. If the sum of (a) through (e)
above is less than all Medical Group expenses as herein described,
then Net Medical Group Revenue will be a negative number.
Section
K-7. Negative Variance in Net Medical Group Revenue
Sections
K-7 and K-8 will be applied after calculation of Net Program Revenue
and Net Medical Group Revenue. If there is a negative Variance in Net
Medical Group Revenue, then Health Plan will pay Medical Group a
portion thereof (multiplied by the number of Eligible Physicians)
according to the following table: Amount of Negative Variance
At
Least
|
Up
To
|
Paid By Health Plan
|
0
|
$
500
|
20%
|
$
500
|
$1,000
|
$100
plus 50% of variance
over $500
|
$1,000
|
No
Limit
|
$350
plus 90% of variance
|
If
application of this Section K-7 is necessary, it will be applied only
once each year.
Section K-8. Positive
Variance
(a)
Reduction in Payments to Medical Group. If there is a positive
Variance in Net Medical Group Revenue, then a portion thereof
(multiplied by the number of Eligible Physicians) will be deducted
according to the following table and applied as provided in Section
K-10:
Amount
of Positive Variance
At
Least
|
Up To
|
Amount
to be Deducted
|
0
|
$
500
|
20%
|
$
500
|
$1,000
|
$100 plus 50% of
variance over $500
|
$1,000
|
No
Limit
|
$350 plus 90% of
variance over $1,000
|
(b)
Addition by Health Plan
If
there is a
positive Variance In Health Plan Cash Generation (after reduction by
any payment under Section K-7), then (i) the amount of such Variance
will be divided by the number of Eligible Physicians, (ii) portions
of the resulting amount will be calculated according to the table set
forth in Section K-8 (a), (iii) the resulting amount (corresponding
to the "Amount to be Deducted" in the foregoing table) will
be multiplied by the number of Eligible Physicians, and (iv) this
amount will be applied as provided in Section K-10.
Section
K-9. Negative Variance in Health Plan
Cash
Generation
If
there is a negative Variance In Health Plan Cash Generation (after
applying Section K-7), then all or
part of the amount thereof
may
at Health Plan's election be included in the next Rate making
Forecast, and the amount thus included will be solely for the account
of Health Plan.
Section K-10. Application of
Positive
Variances After all computations and payments to be made pursuant
to this Agreement have been made, the sum of the amounts, if any,
determined under Section K-8(a) and (b) will be applied first to
reduce Health Plan's negative net worth, if any, and then in
furtherance of general Medical Care Program objectives such as
increasing benefits to Members, adding to or improving facilities, or
minimizing rate increase requirements in future years.
Section
K-11. Limitations on Amendments of Certain Agreements
Health
Plan will not amend the Hospital Service Agreement in a manner that
increases payments to Hospitals and reduces payments to Medical
Group without Medical Group's written consent, and will amend or
rescind the Guaranty Agreement among Health Plan, Kaiser Foundation
Hospitals, Kaiser Foundation Health Plan, Inc. and various
subsidiaries of Kaiser Foundation Health Plan, Inc., executed
effective April 1, 1989 ("Guaranty Agreement") only (a)
with Medical Group's written consent or (b) upon at least 8
calendar months' written notice to Medical Group. If the Guaranty
Agreement is amended or rescinded under (b) without Medical Group's
consent, then (x) all obligations (whether or not then known)
incurred or accrued prior to the effective date of amendment or
rescission will remain subject to the guaranty of the Guaranty
Agreement as now in effect or as it may hereafter be amended, and (y)
"15th month" in Section I-2(e) will be deemed to read "5th
month" if the First Notice is given by Medical Group (but shall
remain "15th month" if the first Notice is given by Health
Plan), but if Health Plan gives a First Notice, then by notice in
writing to Health Plan given within 30 days thereafter Medical Group
may elect to have "15th month" in Section I-2(e) read "5th
month" or any higher number month less than 15.
Section
K-12. Limitation on Changes in Compensation Methods
Neither
Health Plan, Hospitals nor Medical Group will change its system or
method of personnel compensation that is reflected in the Operating
Budget without the consent of both parties hereto."
Article
K
might be found nowhere else but out of this Kansas court site just
outside (Southeast) Kansas City and now copied for web use –
KaiserPapers.org. That would suggest that the individual Kaiser
physicians are to put this material in a very safe place and never
copy it. It is the smoking gun of Permanente profiting 50% from the
Plan income. For other information on the Kansas City court papers
defining Kaiser as a business not a medical care plan with two
partners K and P see on the KaiserPapers.org this selection
https://kaiserpapers.com/kansaswaxman.html
The
supposed limit of global Permanente profit of 10% actually means that
the profit to Permanente cannot exceed the 10% of the entire
Permanente budget – but since almost half of the full budget
if KP
is that of the Permanente contractor (partner) including nursing,
pharmacy, psychologists, clinic staff, supplies, etc. then the
real profit to the partner can be a 100% increase in each
physician’s
salary – which it is. The government chooses to be fooled
into
thinking that a maximum 10% profit sounds about right. The
Colorado Commissioner of Insurance tried to put a profit ceiling on
KP but they fought back and won.
Section
25 –
KAISER PERMANENTE VENTURES – HOSPITALS AND
PERMANENTE
PARTNERS
One of the decisions in the 1997 loss of profit
was to create other ways for Permanente to make money. One was
VENTURE CAPITALISM. Interestingly it is done 50-50 with the
hospitals, a supposed chain of charities. The public will be
surprised to learn that charities can be 49% for profit and still be
IRS non-profits.
For Permanente to invest – and as part of
the Recovery in 2001 Plan or Tahoe Two – they had to
form a
national corporation. That is thePermanente Federation. The
Permanente Federation has a sub-unit for profit unit called The
Permanente Company or Permco for just such transactions.
Permco operate in Oakland, it is incorporated in Delaware.
Mr.
Henry Mead Kaiser was helpful in planning investment schemes for
Permco and the Kaiser Hospitals until he was convicted of a $2
million business fraud. He took $2 million with inside help from a
California company to use in Europe to fake that his investment
schemes were successful.
He is still awaiting sentencing –
probably trying to raise the missing money. He was fired from
KP shortly after Dr. Phillips emailed Kaiser
wondering if he was
still allowed to be on the
Board after confession and
conviction. A more obscure "Kaiser," family member - a pilot for an
airline, took his place
on the
Plan/Hospitals Board; he may still be a secret adviser through
her.
One sure way to make a profit is to try to be on both
sides of contract negotiations. For example, Kaiser contracts out
dialysis. So the Kaiser physicians are heavily involved in Renal
companies. So Plan money spills over to physicians once again.
Sometimes for profit companies are developed within Kaiser –
like
CareTouch – and then spun off as a $14 million company with
Dr.
Lawrence still on board. And there are others. Sometimes Kaiser
summarizes all of its ventures, but the public probably only gets to
see the tip of the iceberg.
Only the FBI, Medicare or the Office of The Inspector General would
have the clout to go in and analyze all of these transactions. But what
President would like to go after a $25 billion operation like Kaiser
with all of its lobbying power? That would require a President to
recall whohe or she represents through election.
Section
26 –
ANALYZING KAISER’S 990 FORM "CHARITY’ ACTIVITY V.
IRS
INTENT
The IRS requirements for non-profit health plans
and non-profit hospitals are clear and different. There is also the
requirement once a year to present a public 990 report. In fact,
Kaiser will send copies free if requested of the Oakland central
accountant. It is always ready six months after April 15th, the
excuse being that it combines all of the state programs and thus is
too complex to be done on time. This means that Kaiser gets the bond
publicity about the profits six months before anyone can really look
at them. And Fitch bond rating has become less than independent
–
allowing false statements like "non-profit" near KP even as
profits are presented.
Corporations try to use their 990
forms to brag about how much charity they are doing. They
rarely
show first how much the government would require them to do to avoid
taxes. What they don’t expand upon is what they consider
charities,
particularly if it is things that help raise profit or reduce
expenses. At some time these expenditures will be carefully
reviewed.
Section
27 –
THE KAISER FAMILY FOUNDATION – NOT INDEPENDENT
The
Kaiser Family Foundation has always tried to look independent from
KP, but they know that KP might be the only chance for a positive
family legacy. Otherwise Henry Kaiser might be remembered for things
like the 100 plus deaths at Hoover Dam. Plenty of money has changed
hands – e.g. startups in Utah, Colorado, Ohio, and Hawaii.
And a
family member is always on the Kaiser Plan/Hospitals Board.
Henry
Kaiser industries developed for the family an endowment of $50
million. Interest is spent each year – perhaps $3 million.
Some of
the spending is aimed at Universities like Harvard
and Stanford
for Henry Kaiser Positions, endowed chairs. And these universities help
KP at regular
intervals in news stories.
While stating that they are
independent of KP, the record is different:
1.
"In
January 1958, however, Kaiser began building a hospital on Waikiki
Beach a few
hundred yards from the Hawaiian
Village hotel. He
financed this effort with a $2.5 million
grant from the Henry
J. Kaiser Foundation." (Smillie book p. 182);
2. Then there was the Detroit loan of $2 million to
try to start
up a Kaiser in Michigan – (Smillie
- p. 227);
3. The KFF helped Kaiser start up in
Colorado as well
(Smillie p. 253). Perhaps another topic that needs to be followed is
the Kaiser Foundation International
– Smillie p.220.
Section
28 –CONTROLLING UNIVERISTIES WITH MONEY AND ENDOWED POSITIONS
At
one time Kaiser got many of its treatment guidelines from Milliman
&
Robertson, a company in the State of Washington also helping
Group Health of Seattle. This company would in turn try to make its
guidelines look like they were coming from Universities by offering
money for university departments. The lid was blown off when several
pediatricians in Houston sued M&R for guidelines using
their names; one was the suggestion that children with meningitis could
go
home in 2 days.
So the whole managed care industry became
more stealthy in their influence of universities, as M&R
remained
a background enabler. For Kaiser this includes:
1. a Henry Kaiser,
Sr. endowed position at Johns Hopkins and Stanford;
2.
payment
to Harvard School of Public Health to help the KFF develop surveys that
are than published in the Washington Post; the
newspaper’s payment for what is supposed to be news is very
questionable;
3. then there is the Stanford-Kaiser
joint
emergency residency;
4. there is
considerable interaction "partnership" with Kaiser research
and the Oregon Health Science center discussed elsewhere;
5.
there are projects between Kaiser and UC Berkeley School of Public
Health.
Then
these same locations become endorsing sources as to Kaiser’s
health
care when the PR department puts out "news" stories. The
main physician who helped Kaiser with their pill-splitting program
was a Dr. Stafford who came out from Yale to Stanford as he published
that pill splitting was okay.
This will be discussed in the
next section. He came to the department of Stanford that does outcome
research and has a Henry Kaiser endowed position within this unit.
(Stanford University pharmacy does not split pills, so the
‘Safford’
article was more for HMO dependent patients than university patients;
Yale probably does not condone splitting either.)
Section
29 –
THE PILL SPLITTING CASE – "AFTER
MARKET"
MEDICATION TAMPERING
I, Dr. Phillips, worked at the
Kaiser ER in Fresno between the Fall of 1997 and the Spring of 1999.
I noticed that many patients had pill splitters in their bags of
medicine. These little blue splitters had a lot of dust and created
pill pieces that were of various sizes. Then I wrote a prescription
for myself of Lisinopril 20 mg a day for high blood pressure and got
back a bottle of Lisinopril 40 mg with the directions of &
frac12; tablet (thus a split) each morning.
I asked for where
was the split authorization on MY prescription. The answer is that I
agreed to all of Kaiser’s policies when I signed on even
though
there was no physician orientation book. Then I got to see a copy
of the system-wide splitting list from Oakland. Kaiser later tried to
say that the list was not copied there but it actually shows that
the copy was from the Fresno pharmacy fax machine
and
done right
there.
I realized that this was not about Kaiser Fresno but
rather the whole national HMO system. Phone calls confirmed that this
was going on from Washington, DC Kaiser to Kaiser Hawaii. Kaiser San
Francisco resisted but then later joined in – economic
pressure
from Oakland that puts all clinical units in business competition
with each other.
As I did more research, I found out that the
weighing studies done elsewhere showed that pill spitting of pills
with or without lines introduced pill variations from 40% to 60% of
the prescribed dose. So it makes no medical sense except for brief
patient titration on the way to a regular dose.
The practice
of pill splitting was begun by the VA at Long Beach Family Practice
Department and then was picked up by Kaiser with its 300 pharmacies
(the "pill halving" program). [See Timmis v. Kaiser law
suit – judges stating that regulatory agencies have the
responsibility to investigate this, yet there is regulatory
silence.] 2007 - I will make my 6th try to the Board of
Pharmacy on pill fragmenting - 06/27/2007.
Actually, the VA pharmacist involved in writing up
the success of pill splitting was next found employed in Kaiser
Vallejo. I tried to see if government was interested in the problem:
1. Food and Drug
Administration – this is an "after market" problem so
they don’t get involved; [yet they do with recycling of
single use
cardiac catheters after Newsweek published the practice];
2.
ARC – chose not to get involved in the policy question; the
lead
physician on quality. Dr. Eisenberg took no stand;
3.
Surgeon General –
made sure the AMA tied the practice to physician’s not just
pharmacists,but
no objection was offered;
4.
California Pharmacy Board – opened a file and then never
answered -
file still open;
5. California Medical Board
– opened a
file and then never answered – file still open;
6.
California Department of Managed Health Care – look at the
issue
and decided to stay out of it.
What
it means is that the government allows Kaiser to give a patient a
blood pressure medication like lisinopril with doses cut (fragmented),
varying from 16
mg to 24 mg. And, in fact, seniors liked to take these fragments from
big to little and end up licking dust as the final dose (ABC News
verified this). Dr. Stafford never allowed for this.
Incidentally,
the VA has never approved splitting officially but has saved a ton of
money doing it.
Not only is pill splitting immoral and
unethical as it randomizes treatment doses, but it is a biopsy of
the whole Kaiser HMO’s race for profits regardless of
science. Any
physician not playing ball with this program would have his pharmacy
costs go up and be found to be "managed care unsuitable."
The two-year observation period is to get rid of physicians with such
Hippocratic ethics.
Kaiser messes around with other
medications. For example, it saves money by having women use oral
pills vaginally rather than use vaginal suppositories. This is not
FDA approved but Kaiser does not care.
Diabetics were also
steered for years toward Tolinase (tolbutamide) for glucose control
until 2006. Yet the
PDR talks about the pills side effects requiring more testing than
normal. Kaiser does not offer this testing. One patient in Pittsburg,
California was given Tolinase to split. When he became sick on the
pill, he was told it would take about a month to get in to make a
change. When that visit came, he was told he didn’t have
diabetes
after all. One Stanford pharmacist I talked to called Tolinase a
"museum" medicine.
Section
30 –
CHANGING LAB VALUES REPORT BY DR. PHILLIPS TO
CONGRESS AND
HARP
I,
Dr. Phillips, was asked by a
Congressional aid to write up the problem of lab testing at Kaiser. I
did so and turned it in to Senator Grassley’s committee. The
notebook size report can be found on HARP.org and the
KaiserPapers.org.
Kaiser’s
lab testing strategies
include all of the following:
1.
under-reading
stress test to
tell people that they don’t have angina when they do;
2.
hemoglobin normals are changed to find fewer anemias (thus catching
less right colon cancer);
3.
kidney tests normals
are changed
(like creatinine to 1.5) to discover less renal disease; I
think
that I convinced them to
quit this.
4.
lipid testing is done with patient having eaten – Los Angeles
Kaiser started this;
5.
testing for Lyme disease is
done wrong
so as to catch less Lyme disease;
6.
MRI’s
are not read
thoroughly, thus finding less disease;
7.
Etc.
Knowing
that the government does not care, Kaiser has continued with all of
this. The less illness found among their 8 million people, the
less money is spent on treatment or more left over from premiums
to create massive profit.
Section
31 – CLINICAL PRACTICE GUIDELINES – CHEAPEST CARE
POSSIBLE
In
1997 Kaiser – as a way to pull out of low profits –
developed the
Care Management Institute to try to get all Kaiser physicians to
practice the same way. The CMI was to come up with treatment
guidelines. Physicians would be forced to change as Kaiser "made
it easier to do the right thing."
Although Kaiser
supports this effort with its charity monies, the CMI Guidelines are
kept secret. They are to be used as "evidence" for
giving patients less care. Opposite from the Mayo Clinic, Kaiser,
for example, does not think stool testing for blood is helpful
(missing more right colon cancer). This is all manipulation by
Permanente physicians. These Clinical Practice Guidelines (for
outpatient
care)
can be found at
https://kaiserpapers.com/cajud.html
Kaiser hospital
libraries still have these protocols as full notebooks. [These
libraries have old textbooks that are often castoffs of texts from
better hospital libraries.] And now these guidelines popup as "the
right thing to do" in the frontline office all over the country
in Kaiser clinics. The inpatient guidelines are called Clinical
Practice Pathways. A few of the standard orders pages can be found
online.
Section
32 – KAISER HOSPICE AND NURSE
"CLOSERS" – DOUBLE MORPHINE SYRINGES
This
section in the future will discuss the case in the Bay Area where a
woman was killed by overdose of medications. There were two morphine
syringes involved – one well tracked and the other with no
tracking. This section will also discuss the Kaiser ABC Kit and
recommendations to use more morphine for shortness of
breath.
Section
33 – PATIENT LOSES LEG AT KASIER
–POOR DIFFERENTIAL DIAGNOSIS AND
TAMPERED LAB TESTING
This
case involves a man in San Jose who had clotting of veins and
arteries. Kaiser missed the diagnosis and then covered up its
tracks. The man lost his leg. See “Sharon and Gary
Rushford”
information on KaiserPapers.org.
Section
34 – HUGE POTASSIUM DOSES – THE VICKIE TRAVIS STORY
ABOUT HER
DAD
This
case is well described by Vickie Travis near the
beginning of her website called KaiserPapers.org. It is also in
the Congressional Record (Kaiser not contesting the truth).
I
was able to confirm all of her story – dirty techniques of
home
care, overdoses of oral potassium, cover-up with diagnosis,
selective removal of lab data, etc. When Vickie Travis finally
obtains full records, Kaiser’s care will be transparently
awful.
Section 35 –
WRONG CARE FOR PROLAPSED CORD –
BABY DEATH IN OAKLAND
This case will be developed here in
the future. The Kaiser physician pushed a baby’s prolapsed
umbilical
cord
against the baby’s head. The child was born blue and died on
a
respirator at home 16 days later. Kaiser beat the father on a court
deadline
technicality.
Section
36 – WRONG CARE OF PREECLAMPSIA
– BABY DEATH IN SAN DIEGO
This Bank of America employee
had a terrible headache showing that she had preeclampsia. It was
called sinusitis. She went home. Her baby was stillborn. Kaiser
offered her $100,000. She said that was too low. Then Kaiser beat her
in "arbitration." The Kaiser representative talked to the
judge on the side which was illegal and immoral. She ended up
losing $20,000. When do patients have the right to sue their
employers for setting up an outfit like Kaiser as if it is a real
health choice?
Section
37 – JAMIE COURT’S BOOK
–"MAKING A KILLING" TOO MANY INFANTS WITH PARALYZED
ARMS (ERB’S PALSY) DUE TO THE USE OF MIDWIVES FOR DIFFICULT
DELIVERIES.
Jamie
Court’s book describes many Kaiser
problems: huge advertising, poor care, too many babies born with
paralyzed arms, etc. More details will be developed here.
Section
38 – KAISER AND EMPLOYEES – CURRENT ILLNESS
– MISSING
SLUDGE CHOLECYSTITIS
Kaiser treats employees as
"internal customers." So when loyal visiting nurses on
three month contracts with Kaiser get sick, Kaiser does not want to
find complicated medical problems. In this case Kaiser did not do
thorough testing and delayed diagnosis.
Section
39 –
KAISER AND EMPLOYEES – FORCING EMPLOYEES TO STAY WITH
KAISER’S
WORK COMP FOR ONE YEAR
Kaiser is one of about a dozen
organizations in California allowed to force their employees to
use their care for a year before having outside physicians involved.
The approach is always employer friendly – employee
unfriendly.
Dina Padilla and April Gottman have organized this part of the
campaign against Kaiser.
Section
40 – KAISER AND
EMPLOYEES –BENEFITS (LOSING YEARS OF RECORDS TO
PAY
A NURSE LESS
IN RETIREMENT)
Kaiser does not like to pay long term
benefits to nurses. So one is not surprised when a nurse found
that Kaiser lost ten years of her records so as to avoid paying her
correct retirement. She has had to fight for a long time just to
prove when she worked. Luckily she kept salary records.
Section
41 – KAISER AND EMPLOYEES – SAFETY VS. ASBESTOS
[This
section will be developed later. Check with Dina Padilla’s
website
for workers.]
Section
42 –
KAISER AND THE MEDICAL BOARD OF CALIFORNIA
Some years ago
the physician experts around California told the Medical Board that at
$50 an hour they were underpaid. They tried to strike and all
were fired. Kaiser then offered their o wn physicians as
replacement. In fact, Kaiser pays them "administrative time"
at the same time as the Board – double dipping. This has
allowed Kaiser to punish critic physicians in yet another way.
This is quite a comeback from the days when Sidney Garfield, MD
lost his medical license by sneaking Dr. Clifford Keene, a
practicing surgeon, back into a residency program at Kaiser so he
could get a California license quickly. There was a time
when the Medical Board tried to keep Kaiser in check. Now it is the
other way around.
Section
43 – KAISER AND THE
CALIFORNIA MEDICAL ASSOCIATION
As the Kaiser Plan pays
for the dues of the Kaiser M.D.s to attend the Medical Societies
around the state, it is not surprising that they gathered enough
votes to put in their own President of the California Medical
Association this year.That will help silence the voice of organized
medicine once again.
Section
44 – KAISER AND THE
DEPARMENT OF MANAGED HEALTH CARE IN
CALIFORNIA
Kaiser
has been fined several times by the DMHC but never significantly
against their $20 billion presence in California alone. Thus the
DMHC has been a dismal failure. Studying these documents in this
presentation you are reading, they could come up with 100 fines. A
good place to start would be false advertising.
Section
45 – HENRY MEAD KAISER - $2 MILLION FRAUD – HAD TO
QUIT
KAISER
PLAN AND HOSPITALS BOARD IN 2004 – NOW
AWAITING FEDERAL
SENTENCING
WHILE TRYING TO PROVIDE RESITITUTION
Many
of us are wondering how you are powerful enough that you can escape
jail time. His sentence kept getting postponed. Now he had found
God he says and the court ruled that he can remain free. Perhaps
all those who stole less than $2 million should be freed.
More
on this
later.
Section 46 –
KAISER AND DIRTY ENDOSCOPY –
THE HEPATITIS STORY
The makers of endoscopes for
colonoscopies have exact requirements for safe cleaning, the bowel
being 1/3 bacteria and a common location for viruses. This cleaning
is especially to get rid of Hepatitis C, AIDS (the HIV virus), etc.
But Kaiser’s shortcuts have resulted in patient exposure.
Suddenly
Kaiser has to send out hundreds of letters warning patients about
possible deadly viruses. And some patients have been infected in
this way with Hepatitis C – potential 4% death sentences.
Section
47 –
KAISER'S INDUSTRIAL CLINICS SHARE DIAGNOSES
WITH
EMPLOYERS
In one case the Kaiser report said one patient
had "alcoholic hepatitis" – actually Hepatitis C as he
tried to tell them. There was no GI appointment for nine months until
he simply died of the disease. Kaiser was, no doubt, hoping that he
would lose his job and be off the Kaiser Plan. Although
Kaiser’s
own Permanente Journal articles state that diagnoses should not be
given to employers only work capacity, KP does give out diagnoses all
the time. One purpose is to get patients out of Kaiser who might cost
money. Often the diagnoses are wrong.
More
about this later. [Oregon has finally passed a law to stop such
sharing of diagnoses.]
Section
48 –
CONCLUSION
–
IT
IS AND HAS ALWAYS BEEN SIMPLY ABOUT THE MONEY
Everyone
who reads this material will have to decide to what level of detail
they want from it.
This has been a summary of so far 73 pages. Full printouts of
what
is available in useful articles, magazines, and books could easily
fill an encyclopedia. Full boxes of records on Kaiser Permanente
could fill up a baseball diamond with boxes.
This
is a huge HMO with a yearly money flow of $25 billion. It is for
profit in that the for profit physicians are the P part of KP, and
they get half of he profits.
Every year we get closer to revealing Kaiser’s
reality to the
world. Transparency is the best
chance for change.
Charles
Phillips, MD, FACEP
SOURCES
In
a court of law or testimony before Congress it is important to have
backup material so that the expert is more of a tour guide than an
advocate. The Kaiser materials speak for themselves when put in the
proper order. If Kaiser testifies against Kaiser, then judges or
newspaper reporters have an easier time getting to the
truth.
1.Edgar
Kaiser message through Ehrlichman to President Nixon that
KP
is for profit and makes
money by doing less – this
leads to the
HMO Act of 1973 designed around
Kaiser.
http://www.whitehousetapes.org/pages/listen_tapes_rmn.htm
for the clearest possible presentation. Check February 17, 1971, 5:26
pm - 5:53 pm, Oval Office Conversation 450-23. Look for: tape
rmn_e450c. It is 12 MGS if using Windows Media Player. (See into to
this investigative article.)
2.The book - Can
Physicians Manage the Quality and Cost of Health Care? - The Story of
the Permanente Medical Group
-gives an accurate history of the growth of Kaiser into the giant
that it is; help and money came from all areas of Kaiser including
the Kaiser
Family Foundation.
Passages
of Interest include:
A. Page 18 - the
original profits
of Sidney Garfield, MD, working out on the desert in the Contractors
Hospital - $250,000 during 5 years on the desert;
B.
Page 116
- the split of partners and non-partners spelled out for the first
and last time;
C. Page 133 -"the Medical Groups,
organized to make a profit."
D. Page 135 -
physicians are
present at "each meeting of the Kaiser Foundation Board";
E.
Page 143-173 - Chapter 8 on "The Tahoe Agreement" which
explains the power and money split among the entities at Kaiser;
F.
Page 144 - the split of the "Retention Fund" 50:50 to the
Hospitals and Permanente physicians [a recurrent theme to this
day];
G. Page 149 - the division of the parts of
Kaiser into
parts to best leverage tax protection;
H. Page 158 -
the
details of the Tahoe Agreement as clarified by the Working Council -
"Excess revenue would be equally distributed" between the
hospitals and the physicians (the Plan then coming out even each
year);
I. Page 168 - more on the same split of 50:50;
J.
Page 173 - again the same split;
K. Page 176 -"the
individual physician was the profit center";
L. Page
239
- Kaiser got government exceptions and all parts became a federally
qualified HMO. Note that Dr. Smillie’s book was supported
financially by The Board of Directors of the Permanente
Medical Group,
the Group Health Foundation, and the Kaiser Family Foundation. And
the Central Office staff of Kaiser
Foundation Health Plan
corrected some misconceptions. [The Kaiser Family Foundation always
states on its website that it is entirely independent of KP; this is
not true – see Section
27.
Kaiser
in 2005 still supports this book and sells it through the main
website for $2 a copy – less than it costs to print.] Dr.
Smillie
was the first Kaiser pediatrician in San Francisco and rose to the
top – "liason from all of the Permanente medical groups to
the
Central Office of the Kaiser Foundation Health Plan in Oakland,
California." (Book Jacket)
3. "Kaiser
Agrees to Disclose Physician Guidelines, Compensation to Settle
Suits"
– newspaper article announcing the conclusion of Olsen/Victa
v.
Kaiser – [the ‘in the hands of doctors" issue];
4.
"A
look inside; Settlement requires Kaiser Permanente to publish info on
docs decision making" – more related to the settlement,
announced originally in a joint news release by Kaiser Permanente and
Jamie
Court’s
organization;
5. Job Bank – Ohio
– Permanente physician
needed – ownership issues;
6. Tax Analysis
of X + Y by which
the IRS allows secondary physician retirement funds to accumulate
untaxed under the Kaiser Plan – "IRS Approves Dual
Organization Deferred Compensation Plan" –
http://pro-adv.com/lissues/
4-98.htm
;
7.
"The Permanente Map"
– designed by Permanente with an ad agency over many hours to
give
a corporate overview – issues of "group
ethic," "Lake Tahoe," the Federation as a fleet, a
water path that makes the doctor-patient relationship a
phase
on the way to
the Permanente patient relationship; etc. all the way to "Our
Sustainable Future" [map not meant by KP to be enhanced and
studied]
8.
Best Guidelines – the American
Diabetic Association (ADA) Clinical
Practice Recommendations – sample of real science although
still
tilted by the internal managed practice committee with in the ADA;
9.
Cheap Guidelines – Kaiser’s
watered down Clinical Practice Guidelines
that search for less disease – details on the Kaiser Papers
website;
10. Worst Guidelines – (Supposed)
Patient friendly
Version accessible by current Kaiser patients (but not by patients
considering joining nor outside physicians);
11.
Stanford
University
– a long Summary of Sources for Review of Diabetes Standards
–
note that Kaiser is the only one that is not public;
12.
"Making
the Right Thing Easier to Do"
by Paul Wallace [actually making it time consuming for any Kaiser
physician to follow his or her own care plan if differing from that
of the non-licensed, top partners];
13. "Electronic
medical record alerts and reminders" – part of a really
unnamed thesis, 107 pages, as work done with Permanente partners
–
KPNW – 2002 as date of publications’ [many hours of
video tape
stored somewhere]:
0. this demonstrates the close
relationship
between Kaiser and the Oregon Health Science University, a
subcontractor to the federal government through "Arc";
1.
Kaiser physicians are asked to work with the EPIC program which
increasingly tells them what to do through their desktop
computers.
2. Prepared Kaiser for the huge contract
with EPIC
– the "E" standing for "embedded" pop-ups
3.
14. "A beautiful mine" – July 2003 – a goal being
"…
all physicians following the same guidelines …" –
the
suggestion being that the best medicine is practiced through central
guidelines coming out of Oakland;
4. 15.
"Transitions of
Clinical Information Systems" (Fall 2003) – (page 11)
"Preprogrammed rules and templates created by KP for charting
and ordering will trigger the decision-support mechanisms" -
this was the IBM CIS predecessor to EPIC;
5. 16.
"This is
Getting Serious" – Fall 2004 – more intense control
of front
line physicians;
6. 17. Stephen B. Adams –
Mr. Kaiser Goes
to Washington – The Rise of a Government Entrepreneur
– Kaiser’s
dependence the government – solving government problem for,in
turn,
being free from real audit.
7. 18. "Kaiser Federal
Home
Loans" - [see if loans are forgiven over time];
8.
19.
"Kaiser's Comeback - Betting on the Durability
of the Integrated Delivery Model"
-check in the blurring of whether Kaiser Permanente could be
nonprofit or just the plan.
9. 20."Southern
California
Physician Recruitment Benefits" - Google search [notice the long
list of financial categories not even including the partnership
split]
10. 21.Executive
Biography of Charles C. Harwood Jr. on Hoovers Online
- note that the Mid-Atlantic Permanente Group is a "for-profit
partnership" [but Permanente is part of the KP "non-profit"
organization the false Kaiser message].
11. 22."The
Latest Stuff from Gerry" – the "20 wrongful death claims
in Dallas County alone."
12. 23. "Millions
are losing their legal rights"
– San Francisco Chronicle - 10/7/01 - about arbitration -"a
system with no laws."
13. 24. IT goes centralized -
"Shock
Therapy at Kaiser Permanente" -
[But check into EPIC and note that it allows Kaiser to put pop ups in
the computer to force all of the physicians to do the same - Oregon
Ph. D. thesis available to show the pop up process being developed
early in EPIC.]
14. 25. Dr. Smillie’s book
which has a whole
last section called "An Essay on Sources."
The
Bancroft Library at UC Berkeley has the Papers of Henry J. Kaiser,
for example, 387 cartons and 208 volumes "for a total of 430
linear feet." The Archives of The Permanente Medical Group –
location unclear – have a large file of internal documents to
unfold the history as well. Kaiser can be understood in one
conversation with Ehrlichman to Nixon, in a short summary of several
pages, in a longer version of now 129 pages, or in full document
examination enough banker’s boxes of materials to fill up a
little
league baseball diamond. With patience, the investigative approach
can understand it all.
CP
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