Kaiser, giant of American prepaid medicine -- the kind of plan that covers almost all your medical and hospital care for a fixed fee each month -- has become a major health care deliverer in the Washington area.
How good is the care?
From the number of members, it's clear that Kaiser has successfully convinced millions that they are well treated. Kaiser health centers now treat nearly 5 million Americans nationwide. After just five years in this area, they care for 145,000.
Still Kaiser, like American medicine itself, can succeed or fail for the individual patient. To deliver affordable care, Kaiser demands that its doctors be "productive," that is, see patients all day at a steady -- meaning sometimes hurried -- clip.
Exactly the same is true of most private practitioners.
A plan like Kaiser does screen its doctors to make sure they all satisfy its standards. You must then be treated only by these doctors. You will not be treated by the "big names" in Washington, unless they are engaged as consultants in special cases.
But neither will you be treated by someone whose skills, behind a glossy reception room, are abysmally low. There are such practitioners.
Dr. Daniel Patterson, Kaiser's chief of psychiatry in the Washington area, said:
"Being a doctor in this plan gives me a good feeling. Our patients want help, and I am able to give it to them. We don't have the copayments or deductibles you find in most health insurance. I think they keep a lot of people from seeking care.
"I think we are able to give good care."
Another doctor, who recently left the Kaiser staff in another eastern city, said:
"Yes, I found the quality of the medical care very good.
"But I didn't have as much time as I liked to talk to my patients. I'm very interested in talking to patients and paying attention to emotions. I'd been used to seeing 12 to 15 patients a day. Kaiser expected us to see 10 or 11 every morning and the same number every afternoon. Really getting involved with a patient takes more time." Yet also, he reported, "Kaiser indoctrinated us in really trying to attract and please patients. They told us it was important that people like us, that they were treated courteously, that they didn't have to wait unduly, that they have a good experience.
"That doesn't sound so radical," but with many doctors "it's not always in the forefront."
"Kaiser" is officially the Kaiser Permanente Health Care Program, which consists of the Kaiser Foundation Health Plan, a nonprofit corporation, plus Permanente Medical Groups, doctors on salary, under contract to the plan.
Kaiser came to Washington in 1980 by buying a medically ambitious but struggling Georgetown University prepaid health plan. The "buyout" really meant assuming more than $5 million in debts, but it gave Kaiser, a child of the West, a major eastern foothold.
The heart of any prepaid health plan is the caliber of its doctors. "Georgetown had 45 high-quality physicians," Dr. Wayne Alberts, Kaiser medical director, said. "We're pleased to say 36 are still with us. And we have a very high physician retention rate," meaning, he said, that the plan gets good doctors and keeps them.
The plan currently has 170 physicians. Fifty-six were added this year. Only two with more than three years with Kaiser left in the past year. Twelve others were "replaced," meaning they either chose to leave or were asked to.
New physicians must be certified or soon become certified by their specialty's examining board. For three years they are on a kind of probation, Alberts said. They then become "full shareholders," eligible for a possible 5 to 8 percent annual bonus, "if the program meets its targets." The targets are attracting, keeping and treating enough members expeditously and economically and keeping them out of costly hospital beds.
In short, even a "nonprofit" plan has to make a profit. "But our main motivation isn't profit," Alan Silverstone, Kaiser's regional manager, said. "It's social commitment. If we make money, the only things that happen are that we keep our dues moderate and build future medical centers."
Of the 170 physicians, the largest number are primary care doctors, mainly internists for adult care and pediatricians for children.
"When you join us, you pick your doctor," Alberts said. "Your doctor will be an internist, or in some cases a board-certified family practitioner. We want you to feel you have a doctor, a physician who takes care of you."
"Your doctor" is also a "gatekeeper," a bit of recent medical economic parlance Kaiser and other such plans abhor. It means your doctor decides in most cases whether or not you should see a further specialist. That, too, keeps the plan's costs down.
"Some people are dissatisfied with this," Alberts acknowledged. "But we believe a single physician has to be responsible for you, rather than fragmenting your care. If you still want to see a specialist, though, we're pretty pliable."
Some patients say this can mean having to insist; others report that it has been no problem.
Disturbingly, Alberts said, about one member in four doesn't pick a regular doctor but simply sees whoever is available. "It's the members who haven't chosen a personal physician who leave us dissatisfied" when they suddenly need care, Alberts added.
The plan also has some nurse practitioners and a few physician's assistants, mainly for some obstetric and well-baby visits, for checks on patients with chronic problems like hypertension and for patient counseling such as teaching diabetics to manage.
Patients with urgent problems, Alberts said, are seen "today," routine appointments take "10 days to two weeks" to schedule -- "it may be three weeks with some physicians in high demand" -- and when you're well but want a physical, it may take up to four to six weeks.
Members can phone day, night and weekends and talk to a registered nurse, and then be on the phone to a doctor "in five minutes," Alberts said. Two after-hours units -- at Washington Adventist Hospital in Takoma Park and at the Kaiser Medical Center in Springfield -- are open 5 p.m. to midnight (expanding to 5 p.m. to 8 a.m. next year). On nights and weekends, "we promise you that 90 percent of the time you'll be seen and out in 40 minutes," he added.
There are Kaiser medical centers in Washington, Falls Church, Reston, Springfield, Gaithersburg, Kensington and Landover (and two new Baltimore area centers, Towson and Woodlawn).
Patients are hospitalized mainly at Arlington, Fairfax, Washington Adventist, Shady Grove Adventist, Holy Cross, Georgetown University and Children's hospitals.
You don't go to the hospital unless it is the only choice. Kaiser's local hospitalization rate is currently 352 days per 1,000 members per year, compared with the area's overall rate of 756 days per 1,000 population.
Starting with the Georgetown plan's 54,000 members in 1980, Kaiser has grown by a remarkable 17,000 to 31,000 a year. About 20 percent leave each year, Silverstone said, but 15 percent leave because they change towns or jobs and only 5 percent "because they want something else."
What do they complain about if they leave? "Price," he said. The latest announced cost is $39.24 every two weeks for a single federal employe (the employe's share is $16.81), and $98.11 for a federal employe and family (employe share: $48.20); non-federal charges are roughly similar.
"Or," Silverstone said, "they say, 'I didn't like my doctor,' 'It was too far to travel,' 'I couldn't use the doctor I wanted.' "
Kaiser insists that employers offer workers a choice of at least one other health plan other than Kaiser. "Even our physicians can belong to us for their care or choose Blue Cross-Blue Shield health insurance . Seventy-five percent belong to us, 25 percent don't. That's all right. We believe in a choice."
"What we have to offer," he summed up, "is quality. Quality medical care. But also, and equally important, quality of caring. Compassion, reassurance, attentiveness.
"That's what we promise."
Is that what you get from Kaiser people if you're a Kaiser patient? If not, show them these words.