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Selected Writings of Dr. Charles Phillips - Former Kaiser Permanente Physician
To the Public: Holiday time is a favorite time for Kaiser or its network of co-enablers to release infomercials that get gobbled up by reporters who don't want to pick up the phone to check details or otherwise delay their holiday focus, e.g., Christmas shopping. Now we have our pre-Christmas consumption that Kaiser is a heart Mecca in California - gag me with a stethoscope Charles Phillips, MD, FACEP
MSNBC.com Kaiser bucks the HMO trend Company offers new approach to health care
By Anne Thompson Correspondent NBC News Updated: 8:00 p.m. ET Dec. 20, 2004
OAKLAND, Calif. - As a member of the Kaiser Permanente HMO in northern California, heart patient Roshni Nand is the exception. Nationwide, heart disease is the leading cause of death, but not for the 3 million members of Kaiser, where it is a stunning 30 percent lower than the rest of California.
I believe many seniors face a deadline before the first of the year for choosing health plans. While Kaiser has spent some $40,000,000 on broccoli ads this year, there may still be some seniors who are undecided. Providing exclusive stories to NBC is another way to get an infomercial. It is probably a payback to ABC who got a TV exclusive some years back on Kaiser's unethical practice of pill splitting.
"Heart patient Roshni Nand is the exception."The article never does establish why Heart Patient Nand is an exception. If she survived a high risk cardiac event, that would have been explained. Rather she has some sort of chronic heart condition from which Kaiser has not prevented in its development.
Heart disease is certainly still the leading cause of death for Kaiser patients in all of its current locations - California, Oregon, Colorado, Georgia, Washington, DC, etc., - as well as all the places it has had to leave - Texas, New York, New England, Missouri, Utah, North Carolina, etc. There is no oasis out here so don't start packing your bags into the covered wagon. That gold in them there hills is still cholesterol.
For a reporter who might have checked out the press release packaged in Oakland, the pseudoscience behind Kaiser's big self hug is a 2002 study done in California covering the years 1996-1998 by the California Hospital Outcomes Project. Note that those years involved the use of a computer system contracted by Dr. Lawrence that was tossed out by Mr. Halverson as a $1 billion mistake.
The $3 billion current figure Kaiser uses for its IT includes the waste of the $1 billion, to keep bond holders from having a clue. As another billion of the $3 billion is used to track physicians so that they do as little as possible for their patients, the system should be condemned by the government rather than complimented.
The heart outcomes data was 100% dependent upon how hospitals translated their care into cardiac codes at the end as well as the outcomes from 1996-1998. Prepaid hospitals like Kaiser as an HMO have less pressure to code correctly and have the capacity as a very closed system to generate any outcome they wish to present to the state. State audits as to accuracy generally occur in notebook filled rooms as the prime rib is brought in for a sumptuous lunch. (At Kaiser's Christmas Ball, this month near Fresno, the door prize was worth $2500, which impressed all the officials invited; the valet parking and coat room were other observed perks.)
The cardiac outcomes in the 2002 study were disputed by many of the hospitals involved. Kaweah Delta Health Care District in Visalia, California, a top hospital in the region, wrote the state that their rating of a 15.2% mortality was in error and the real rate was 11.9. That is a major system error. As a physician who knows the California Central Valley well, I would recommend that with the symptom of chest pain bypassing any Kaiser hospital in favor of Saint Agnes Hospital or Kaweah Delta Hospital would be wise. And I think the state planners involved in this old study would do the same.
It's the result of a simple formula, says Dr. Eleanor Levin.
"Make sure they're on all the right medications," says Levin, a cardiologist with Kaiser Permanente of northern California. "That they're doing the right lifestyle changes in terms of weight loss, stress reduction, smoking cessation and the right diet."
Kaiser Permanente is the only HMO in the country being sued - Timmis v. Kaiser - for the poor quality of its delivered medications. It encourages pills splitting including cardiovascular medications. Seniors who split their pills with Kaiser's pill splitters end up with uneven pieces. The usual two hundred fragments produced are taken from large down to small, some patients licking up dust at the bottom. This is hardly an organization that cares about "right medications" or right doses.
Although Kaiser advertises open trust for all patients, it has a hidden agenda set in place to withhold care from those who have less than perfect life styles (read most of us). In fact, Kaiser does not even offer health care but rather health advice. Patients must manage their own care. And if they cannot lose weight, they are noncompliant by definition. And in these groups Kaiser will not search for illness. Kaiser misses half its diabetics and does not care that it is so.
The Kaiser cardiac workup is also patient unsafe. Abnormal cardiac stress tests are read as normal - see one death in Northern California and one severe cardiac injury in California in Southern California. Half of the patients who normally would be admitted overnight at other hospitals are sent home from a typical Kaiser Emergency Room to bear the risk of a heart attack occurring at home. Cholesterol goals are not the same as the national - e.g., the national being an LDL for diabetics of 100 or less and for Kaiser 130.
Kaiser's own correct heart diets certainly do not appear when Kaiser physicians have staff meetings or the state comes by for a supposed review. Red meat is enjoyed by all.
It's about preventing problems, instead of just reacting to them. It's a coordinated approach reinforced to patients like Nand by doctors and in free classes.
"Your vascular surgeon and your internist and your cardiologist are all giving you the same message," says Levin.
This sounds like a Kaiser failure in cardiac prevention now needing a vascular surgeon. And why not a cardiac surgeon? Kaiser's physicians are all asked to practice just past their level of expertise. It lowers costs and shifts risks to patients.
So what's Kaiser's secret weapon? A $3 billion computer network that gives doctors instant information about X-rays and lab tests, and eliminates hard-to-read prescription orders.
The $3 billion computer network "secret weapon" is about as secret as the War in Iraq. Kaiser has been pushing its existence in every government lobby hall and newspaper in the nation. The trouble is that the old system was just recently tossed out as no good. And few know how to use the new system except those taught this year in Denver. So the computer had nothing to do with the statistics; busy coding hands did this.
"They can simply, with a few clicks, order the medications, order the tests — even the consultations," says Dr. Louise Liang, senior vice president of Kaiser Permanente.
Computers are not licensed to practice medicine and so they cannot consult. And consultations have to do with taking a history, doing an exam, coming up with a group of diagnoses, and testing. Computer "consultation" really means following mandatory popup reminders that cooks all patients at the same temperature.
This integration of medicine and technology in Oakland, Calif., is attracting worldwide interest from Britain's national health service to the Bush administration. Everyone wants to see if Kaiser is a model for the future.
Britain's national health service is quite aware that Kaiser deals with a skewed group of mostly working individuals, not a match to their more public system in England. What they do want from Kaiser is to know how they avoid hospitalizing patients. That is Kaiser's "big secret." The answer is twofold - one, keep them out and, two, rush them out again. When the British pensioners understand it, they will respond with more than a stiff upper lip. Those stiffened in the process will, of course, have no choice.
"The kind of coordination that Kaiser has achieved has set a very high standard and shows us, I think, in many cases, what's possible," says Margaret O'Kane, president of the National Committee for Quality Assurance.
Kaiser helped create the National Committee for Quality Assurance and sits on its Board. This is about the kettle designing the best shade of black. HMOs would love to substitute their set of rules for those of the Joint Commission. NCQA and JCAHO are forever fighting over who is best. They both have serious problems.
It's all a far cry from the 1990s when Kaiser, like many others, was dogged by accusations of putting costs before care. Now, it uses technology to identify issues before they become headlines.
Kaiser lost money in 1997 and 1998 - the first such loss in profit in 60 years. One Kaiser physician in Denver said the morale of the physicians was akin to that of forest rangers after the Yellowstone Fire. Without profit for the physicians, Kaiser would fold in a year. At that time in 1997, a Draconian plan was set afoot called the Recovery Plan for 2001.
Patients were to be cared for by teams, so that personal physicians could step back and spend LESS time with them. Care Guidelines were to force all physicians to practice the same way - don't search for new diabetic patients, don't search for right colon cancer, order fewer tests, underread tests, tell chronic patients to stay home and cope better, let nurses do sigmoidoscopies, split pills, use 1970's pills, etc.
This was, more than ever, COST BEFORE CARE. Fake ads - proven untrue in court - like "in the hands of doctors" were published everywhere. Kaiser Permanente still fakes out the public by pretending that it is "non-profit," the for profit physicians being in charge. "Kaiser Permanente" is not even registered with the IRS at all, it is only a program and logo.
"We actually removed Vioxx as a medication for our patients before the FDA pulled it," says Liang.
"Kaiser has always been against the whole class of COX-2 inhibitors since they cost a lot. Asking Kaiser to study Vioxx, was like asking direct TV to evaluate the cable market."
It's a different way of delivering care, but it's also a different way of doing business. Instead of paying doctors for each service they perform, physicians earn a salary, with bonuses for keeping people healthy.
"For the Kaiser senior partners - perhaps 3000 such physicians - the salary is only a "draw" on the bigger income. First of all, the salaries are about $200,000 a year. Benefits add in another $50,000 benefit. Then there is the huge additional retirement incomes which arise from the "excess revenues" of Kaiser Permanente, perhaps another $150,000 a year.
And, finally, there are the incomes which are derived from the physicians' profit ventures through PermCo including HearEx, CareTouch, Optimal Renal Care, etc. That allows the physicians to be on both sides of contracts - a neat trick Martha Stewart needs to learn while she has free time in January. The bonuses are for calling patients "external customers" and "the worried well" so that they can be ignored until hospice (read morphine) time.
But experts say adopting such a model would take a monumental shift in the health care industry.
"What we pay for in medical care is for doing things — for operating on patients, for prescription drugs ... insurers earn more when their patients do more," says David Cutler, a professor at Harvard University. "But nobody earns more when the patients are healthier."
Nor does Kaiser. Permanente physicians earn more when they diagnose sick patients as healthy, e.g., you're getting old, it's all in your head, give the cortisone a chance, more broccoli less beef, etc. In fact, they even have had the guts in Northern California to redefine the values for anemia - so that less anemis will be found. Harvard likes to help Kaiser with its press releases because of Henry Kaiser endowments at the joint contract Kaiser Family Foundation - Harvard Public Health-Washington Post that keeps information flowing in the right direction.But Kaiser says its influence is felt in northern California, where costs are 25 percent less than the New York area.
"We're able to keep our members healthier; therefore, it costs less to take care of them," says Dr. Francis J. Crosson, executive director of the Permanente Foundation.
Dr. Crosson as the more powerful and more senior half of the two person head of Kaiser Permanente is an expert at cutting costs. And the physicians' windfall of half of the $1.4 billion in profits this year will certainly help him to lead a lifesytle of the rich and famous. HMO Pediatricians do especially well at denying care to the elderly; it is a natural fit.
For patients like Nand, it all adds up to crucial support as she lives with a chronic disease.
Nand clearly did not get her disease prevented. Nor did she get a great restoration. She got a progression to a chronic disease. Most likely she will get assigned to a nurse "Case manager" (read care manager) whose salary only make sense if such patients stay home more when under such supervision. And, in fact, Kaiser's book for patient on chronic care states that all chronic care is about the same, and home care makes the most sense. When in doubt, you can always try to activate the Permanente-patient relationship.
© 2004 MSNBC Interactive
MSNBC - Is this your best effort to inform the elderly as they make their health plan decisions this Christmas?
If I were you I would fear the ghost of Christmas future.
Former Kaiser Physician - Charles Phillips, MD, FACEP
http://www.msnbc.msn.com/id/6738329/
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