In late 1999 United Health Care created a high media fanfare announcing that it would leave medical decisions up to the patient and his or her physician.  Since the announcement a lot more about their "new" policy has come to light.  We have seen that they did not include the mental health division in the new policy (these are the patients who are least likely to be able to speak up for themselves) and that the physicians would be held to task for ordering too many expensive procedures and tests - to the point of being kicked out of the network and/or having their reimbursement for the procedures retroactively denied.  Basically that meant that if a physician spent too much (what UHC thought was too much, not necessarily what their peers thought was excessive) he or she stood to lose all his or her patients and, on top of it all, to not be paid for the work that they already did.  All UHC did, in this announcement, was transfer the burden of providing services to their already beleaguered practitioners therefore shielding themselves from what they saw coming out of Washington in the form of the Norwood-Dingell Patients Bill of Rights legislation.

How Kaiser Responded

The story was so big that Kaiser Permanente took the unusual step of faxing reporters immediately following United HealthCare's announcement.   Kaiser offered to let the media interview "senior [Kaiser] physicians... to comment on... United Health's decision." Why would Kaiser feel the need to respond so urgently to an announcement by another health plan? "Because all the leading newspapers implied that this was a breakthrough, so Kaiser felt the need to clarify things," says Robert Pearl, M.D., executive director and CEO of the Permanente Medical Group, in Oakland. "We have been doing this for 50 years and plan to continue to leave decision making between physicians and their patients for the next 50."

The low-down by Chuck Phillips, M.D.

I recently worked 18 months in the Kaiser Emergency Room in Fresno, California --often exceeding the monthly hours of the full time physicians.  The idea that decisions are in the hands of the individual treating physician and the patient being treated is a complete hoax.  Here are a few experiences I had in this environment:

  1. my physician boss wrote memos to all of us that we could only give three days off to any employee with an injury, that we would have to follow Treatment Guidelines to the letter,  that our speed should be 2-3 patients an hour (though the national average is 2.8 per hour without the critical care streaming of those seen in the Kaiser ER), and that we need not order the most common heart attack test in the first six hours of pain;
  1. pharmacists will change physician prescriptions without notifying the physician who wrote it - I even wrote one to myself to prove it;
  1. non-physician unit managers are generally empowered way beyond the physician manger to make decisions - such as was true in our unit;
  1. lumbar spine MRI's could only be ordered with the approval of the back clinic physician; this came from the head of radiology but was then denied by the back clinic physician - so it was a fictitious bluff;
  1. ultra sound simply went home at 5 p.m. with no backup -- so how could this test even be ordered? (some make this the chief reason they will not work here);
  1. one carotid ultrasound I ordered could only be done if I first convinced a neurologist on call to agree; he happened to be in Sacramento and unaware that he was on "neuro call"  to Fresno;
  1. that phone message consults to specialists were being phased out with only written consults (so as to score physicians on number of consults -- thus affecting the ? $15,000 "productivity" bonus);
  1. that hospitalist internists would routinely send home patients that board certified emergency physicians thought needed admission;
  1. that the same internists would then be pressured by utilization review to discharge unstable patients -- one patient dying in the middle of the hallway argument about discharge just outside his room;
  1. that excessive ordering would be punished by passive aggressive delays in giving back tests results -- one physician watching a TV football game rather than reading an emergency CT scan;
  1. that IVs ordered by physicians to be continuous would routinely go dry from lack of attention to empty IV bags;
  1. that the "therapeutic waiting" in the lobby would create such hostility to the physician that the first few minutes of most patient encounters had to begin with venting "fortress Kaiser" feelings;
  1. that patient advocacy to the point of threatening career physician licenses was non-collegiate and counterproductive to internal "channels" -- the latter a rival to the black holes in space;
  1. that "open door policy" to the physician-in-chief equated to three letters from another physician not answered;
  1. that staff should not request more help when overburdened but remember that Kaiser is a "mean machine."

 This is the most anti-physician setting in the Valley.  My documentation file exceeds three inches.  They refuse to debate me in any forum.

 While it may be "in the hands of doctors" who have ERISA protection as coaches at the top, it is certainly not in the hands of physicians at the bottom.  Those physicians who stay have either been "Kaiserized" into accepting compromised care or who are self described "slaves" working unpaid hours into the night trying to do the job right.  Even the physicians inside have complained in an internal newsletter "Hope" that the $100 million spent now per year on advertising might better be spent on patient care.

This would not be the best time to brag about a  50 year success story about to clone itself into the future.  This would be a better time to rebuild the entire system around the few physician stars still hanging on within. 

                     Chuck Phillips, MD - past Kaiser physician

PS Kaiser actually tries to distance itself from its own exclusive, physician group called The Permanente Medical Group (TPMG) -- who shares its headquarters, advertising, lawyers, etc. -- so that proven mistakes can be blamed on outside "contractors" as in the "Death by HMO" book example.