Kaiser Permanente

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Kaiser Permanente
Industry Healthcare
Founded 1945
Founder Henry J. Kaiser
Sidney R. Garfield
Headquarters Ordway Building
Oakland, California, USA
Key people
Bernard J Tyson,
Health Plan and Hospitals CEO
Jack Cochran, M.D.,
Federation Executive Director
see section below
Revenue Increase $53.1 billion USD (2013)[1]
Increase $1.6 billion USD (2011)[1]
Number of employees
181,900 total
164,098 employees (2009)
15,129 physicians (2008)[2]>
Website kp.org

Kaiser Permanente is an integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser Permanente is made up of three distinct groups of entities: the Kaiser Foundation Health Plan and its regional operating subsidiaries; Kaiser Foundation Hospitals; and the autonomous regional Permanente Medical Groups. As of 2014, Kaiser Permanente operates in eight states and the District of Columbia, and is the largest managed care organization in the United States.

Kaiser Permanente has 9.3 million health plan members, 167,300 employees, 14,600 physicians, 37 medical centers, and 611 medical offices.[2] For 2011, the non-profit Kaiser Foundation Health Plan and Kaiser Foundation Hospitals entities reported a combined $1.6 billion in net income on $47.9 billion in operating revenues.[1] Each independent Permanente Medical Group operates as a separate for-profit partnership or professional corporation in its individual territory, and while none publicly reports its financial results, each is primarily funded by reimbursements from its respective regional Kaiser Foundation Health Plan entity.

Structure and governance[edit]

Kaiser Permanente's headquarters (the Ordway Building in downtown Oakland)
One of Kaiser's six other office buildings in Oakland

Kaiser Permanente provides care throughout seven regions in the United States. Two or three (four, in the case of California) distinct but interdependent legal entities form the Kaiser system within each region. This structure was adopted by Kaiser Permanente physicians and leaders in 1955.

National structure[edit]

The two types of organizations which make up each regional entity are:

  • Kaiser Foundation Health Plans (KFHP) work with employers, employees, and individual members to offer prepaid health plans and insurance. The health plans are not-for-profit and provide infrastructure for and invest in Kaiser Foundation Hospitals and provide a tax-exempt shelter for the for-profit medical groups.
  • Permanente Medical Groups are physician-owned organizations, which provide and arrange for medical care for Kaiser Foundation Health Plan members in each respective region. The medical groups are for-profit partnerships or professional corporations and receive nearly all of their funding from Kaiser Foundation Health Plans. The first medical group, The Permanente Medical Group, formed in 1948 in Northern California.

In addition, Kaiser Foundation Hospitals operates medical centers in California, Oregon and Hawaii, and outpatient facilities in the remaining Kaiser Permanente regions. The hospital foundations are not-for-profit and rely on the Kaiser Foundation Health Plans for funding. They also provide infrastructure and facilities that benefit the for-profit medical groups.

Regional entities[edit]

Kaiser Permanente is administered through eight regions, including one parent and five subordinate health plan entities, one hospital entity, and nine separate, affiliated medical groups:

  • Northern California, 3,351,449 members[3]
    • Kaiser Foundation Health Plan, Inc. (KFHP)
    • Kaiser Foundation Hospitals (KFH)
    • The Permanente Medical Group, Inc. (TPMG)
  • Southern California, 3,499,035 members
    • Kaiser Foundation Health Plan, Inc. (KFHP)
    • Kaiser Foundation Hospitals (KFH)
    • Southern California Permanente Medical Group (SCPMG)
  • Colorado, 531,908 members
    • Kaiser Foundation Health Plan of Colorado (KFHPCO)
    • Colorado Permanente Medical Group, P.C. (CPMG)
  • Georgia, 222,074 members
    • Kaiser Foundation Health Plan of Georgia, Inc. (KFHPGA)
    • The Southeast Permanente Medical Group, Inc. (TSPMG)
  • Hawaii, 226,900 members
    • Kaiser Foundation Health Plan, Inc. (KFHP)
    • Kaiser Foundation Hospitals (KFH)
    • Hawaii Permanente Medical Group, Inc. (HPMG)
  • Mid-Atlantic (vicinity of Washington, D.C., including Maryland and Virginia), 488,269 members
    • Kaiser Foundation Health Plan of the Mid-Atlantic States Inc. (KFHPMA)
    • Mid-Atlantic Permanente Medical Group, P.C. (MAPMG)
  • Northwest (Northwest Oregon and Southwest Washington), 480,386 members
    • Kaiser Foundation Health Plan of the Northwest (KFHPNW)
    • Kaiser Foundation Hospitals (KFH)
    • Northwest Permanente, P.C. Physicians and Surgeons (NWP)

In addition to the regional entities, in 1996, the then-twelve Permanente Medical Groups created The Permanente Federation, a separate entity, which focuses on standardizing patient care and performance under one name and system of policies. Around the same time, The Permanente Company was also chartered as a vehicle to provide investment opportunities for the for-profit Permanente Medical Groups.[4] One of the ventures of the Permanente Company is Kaiser Permanente Ventures, a venture capital firm that invests in emerging medical technologies.[5]


Each entity of Kaiser Permanente has its own management and governance structure, although all of the structures are interdependent and cooperative to a great extent.

Chairman and CEO George Halvorson retired in December, 2013, after serving since 2002.[6]

On November 5, 2012, the board of directors announced that Bernard Tyson, Kaiser's president and chief operating officer for the last two years, would replace Halvorson.[7] He is now the current CEO and is the first African American to hold that position.[2]

Board of Directors[edit]

As of 2014, the following 12 directors serve on the Kaiser Permanente Board:[8]

  • Bernard Tyson (Chairman and Chief Executive Officer)
  • Kim Kaiser
  • Thomas Chapman
  • Daniel Garcia
  • J. Grigsby III
  • Philip Marineau
  • Edward Pei
  • J. Purcell
  • Cynthia Telles
  • William Graber
  • Jennifer Ming
  • Judith Johansen

Medical centers[edit]

As of June 2014, Kaiser operates in the following states:

  • California
  • Colorado
  • Virginia
  • Maryland
  • District Of Columbia
  • Oregon
  • Washington
  • Georgia
  • Hawaii

Medical centers include:

  • Antioch Medical Center
  • Baldwin Park Medical Center
  • Downey Medical Center
  • Fremont Medical Center
  • Fontana Medical Center
  • Hayward Medical Center, includes emergency medical services. Opened in 1957, and scheduled to close, to be replaced by the San Leandro Medical Center. Reasons for the closure include not meeting state seismic standards.[9]
  • Livermore Medical Center
  • Los Angeles Medical Center
  • Manteca Medical Center
  • Martinez Medical Center
  • Modesto Medical Center
  • Moanalua Medical Center
  • Moreno Valley Medical Center
  • Oakland Medical Center
  • Orange County - Anaheim Medical Center
  • Orange County - Irvine Medical Center
  • Panorama City Medical Center
  • Palomar Medical Center
  • Pleasanton Medical Center
  • Redwood City Medical Center
  • Richmond Medical Center
  • Riverside Medical Center
  • Roseville Medical Center
  • Sacramento Medical Center
  • San Diego Medical Center
  • San Jose Medical Center
  • San Mateo Medical Center
  • San Francisco Medical Center
  • San Leandro Medical Center, scheduled to open in late 2014 with emergency medical services.[9][10]
  • San Rafael Medical Center
  • Santa Clara Medical Center
  • Santa Rosa Medical Center
  • South Bay Medical Center
  • South Sacramento Medical Center
  • South San Francisco Medical Center
  • Stockton Medical Center
  • Sunnyside Medical Center
  • Tracy Medical Center
  • Vacaville Medical Center
  • Vallejo Medical Center
  • Walnut Creek Medical Center
  • West Los Angeles Medical Center
  • Westside Medical Center
  • Woodland Hills Medical Center

Former centers[edit]


Kaiser Sunset Hospital complex in Los Angeles, California

Early years[edit]

Though it has since become the largest organization of its kind, Kaiser was not the first HMO. In its modern form, the HMO combines a large group practice, contracts with employers to care for a group of workers, and a prepayment plan for both hospitals and group practices. The first "contract doctor" system in the West was orchestrated by Dr. Raymond G. Taylor, who created a temporary healthcare system from 1908 to 1912 on behalf of the Los Angeles Board of Public Works to care for the 10,000 workers on the Los Angeles Aqueduct project. The first group prepayment plans appeared in 1929 in response to the onset of the Great Depression. That year, Baylor University started a hospital prepayment plan, the first of several plans which would ultimately join together to become the Blue Cross insurance network. In Oklahoma, Dr. Michael Shadid recruited local farmers around Elk City, Oklahoma into a small consumer healthcare cooperative. And in Los Angeles, Dr. Donald Ross and Dr. H. Clifford Loos founded the Ross-Loos Clinic to care for City of Los Angeles public utilities workers.[11]

The history of Kaiser Permanente dates to 1933 and a tiny hospital in the town of Desert Center, California. At that time, Kaiser and several other large construction contractors had formed an insurance consortium called Industrial Indemnity to meet their workers' compensation obligations. Dr. Sidney Garfield had just finished his residency at Los Angeles County-USC Medical Center at a time when jobs were scarce; fortunately, he was able to secure a contract with Industrial Indemnity to care for 5,000 construction workers building the Colorado River Aqueduct in the Mojave Desert. Soon enough, Garfield's new hospital was in a precarious financial state (with mounting debt and the staff of three going unpaid), due in part to Garfield's desire to treat all patients regardless of ability to pay, as well as his insistence on equipping the hospital adequately so that critically injured patients could be stabilized for the long journey to full-service hospitals in Los Angeles.[12]

However, Garfield won over two Industrial Indemnity executives, Harold Hatch and Alonzo B. Ordway. It was Hatch who proposed to Garfield the specific solution that would lead to the creation of Kaiser Permanente: Industrial Indemnity would prepay 17.5% of premiums, or $1.50 per worker per month, to cover work-related injuries, while the workers would each contribute five cents per day to cover non-work-related injuries. Later, Garfield also credited Ordway with coming up with the general idea of prepayment for industrial healthcare. Garfield also later explained that he did not know much at the time about other similar health plans except for Ross-Loos.[13]

Hatch's solution enabled Garfield to bring his budget back into the positive, and to experiment with providing a broader range of services to the workers besides pure emergency care. By the time work on the aqueduct concluded and the project was wrapped up, Garfield had paid off all his debts, was supervising ten physicians at three hospitals, and controlled a financial reserve of $150,000.[14]

Garfield returned to Los Angeles for further study at County-USC with the intent of entering private practice. However, in March 1938, Consolidated Industries (a consortium led by the Kaiser Company) initiated work on a contract for the upper half of the Grand Coulee Dam in Washington state, and took over responsibility for the thousands of workers who had worked for a different construction consortium on the first half of the dam. Edgar Kaiser, Henry's son, was in charge of the project. To smooth over relations with the workers (who had been treated poorly by their earlier employer), Hatch and Ordway persuaded Edgar to meet with Garfield, and in turn Edgar persuaded Garfield to tour the Grand Coulee site. Garfield subsequently agreed to reproduce at Grand Coulee Dam what he had done on the Colorado River Aqueduct project. He immediately spent $100,000 on renovating the decrepit Mason City Hospital and hired seven physicians.[15]

Unlike the workers on Garfield's first project, many workers at Grand Coulee Dam had brought dependents with them. The unions soon forced the Kaiser Company to expand its plan to cover dependents, which resulted in a dramatic shift from industrial medicine into family practice and enabled Garfield to formulate some of the basic principles of Kaiser Permanente. It was also during this time that Henry Kaiser personally became acquainted with Garfield and forged a friendship which lasted until Kaiser's death.[16]

World War II[edit]

Kaiser Field Hospital in Richmond, California. Defunct since 1995

In 1939, the Kaiser Company began work on several huge shipbuilding contracts in Oakland, and by the end of 1941 would control four major shipyards on the West Coast. During 1940, the expansion of the American defense-industrial complex in preparation for entrance into World War II resulted in a massive increase in the number of employees at the Richmond shipyard.[17] In January 1941, Henry Kaiser asked Garfield to set up an insurance plan for the Richmond workers (this was merely contract negotiation with insurance companies), and a year later Kaiser asked Garfield to duplicate at Richmond what he had done at Desert Center and Mason City.[18] Unlike the two other projects, the resulting entity lived on after the construction project that gave birth to it, and it is the direct ancestor of today's Kaiser Permanente.[19]

On March 1, 1942, Sidney R. Garfield & Associates opened its offices in Oakland to provide care to 20,000 workers, followed by the opening of the Permanente Health Plan on June 1.[20] From the beginning, Kaiser Permanente strongly supported preventive medicine and attempted to educate its members about maintaining their own health.[21]

In July, the Permanente Foundation formed to operate Northern California hospitals that would be linked to the outpatient health plans, followed shortly thereafter by the creation of Northern Permanente Foundation for Oregon and Washington and Southern Permanente Foundation for California. The name Permanente came from Permanente Creek, which flowed past Henry Kaiser's first cement plant on Black Mountain in Cupertino, California. Kaiser's first wife, Bess Fosburgh, liked the name. The first Permanente Hospital opened in Oakland on August 1, 1942. Three weeks later, the Richmond Field Hospital opened, and the Northern Permanente Hospital opened two weeks later to serve workers at the Kaiser shipyard in Vancouver, Washington.[22] In 1944, Kaiser decided to continue the program after the war and to open it up to the general public.[19]

Meanwhile, during the war years, the American Medical Association (AMA) (which opposed managed care organizations from their very beginning) tried to defuse demand for managed care by promoting the rapid expansion of the Blue Cross and Blue Shield preferred provider organization networks.[23]

Courage to Heal, a novel by KP Historical Society President, Paul Bernstein, MD, is based on the story of Garfield's life, his struggles with the AMA, and the origins of Kaiser Permanente.

Postwar growth[edit]

The end of World War II brought about a huge plunge in Kaiser Permanente membership; for example, 50,000 workers had left the Northern California yards by July 1945. Membership bottomed out at 17,000 for the entire system but then surged back to 26,000 within six months as Garfield aggressively marketed his plan to the public.[24] Sidney Garfield & Associates had been a sole proprietorship, but in 1948, it was reorganized into a partnership, Permanente Medical Group.[25]

During this period, a substantial amount of growth came from union members; the unions saw Kaiser Permanente care as more affordable and comprehensive than what was available at the time from private physicians under the fee-for-service system. For example, Fortune magazine had reported in 1944 that 90% of the U.S. population could not afford fee-for-service healthcare. Kaiser Permanente membership soared to 154,000 in 1950, 283,000 in 1952, 470,000 in 1954, 556,000 in 1956, and 618,000 in 1958.[26]

From 1944 onward, both Kaiser Permanente and Garfield fought numerous attacks from the AMA and various state and local medical societies. Henry Kaiser came to the defense of both Garfield and the health plans he had created.[27]

In 1951, the organization acquired its current name when Henry Kaiser unilaterally directed the trustees of the health plans, hospital foundations, and medical groups to add his name before Permanente.[28] However, the physicians in the Permanente Medical Group deeply resented the implication that they were directly controlled by Kaiser, and successfully forced him to back off with respect to their part of the organization. That same year, Kaiser Permanente also began experiments with large-scale multiphasic screening to identify unknown conditions and to facilitate treatment of known ones.[29] Simultaneously, although no one questioned his medical competence, Garfield's deficiencies as an executive were becoming apparent as the organization expanded far beyond his ability to manage it properly.[30]

Henry Kaiser became fascinated with the healthcare system created for him by Garfield and began to directly manage Kaiser Permanente and Garfield. This resulted in a financial disaster when Kaiser splurged on the new Walnut Creek hospital; his constant intermeddling led to significant friction at every level of the organization. The situation was not helped by Kaiser's marriage to Garfield's head administrative nurse (who had helped care for Kaiser's first wife on her deathbed), convincing Garfield to marry the sister of that nurse, and then having Garfield move in next door to him. Clifford Keene (who would eventually serve as president of Kaiser Permanente) later recalled that this arrangement resulted in a rather dysfunctional and combative family in charge of Kaiser Permanente.[31]

Keene was an experienced Permanente physician whom Garfield had personally hired in 1946. During 1953 he had been trying to get a job at U.S. Steel, but on the morning of December 5, 1953, with internal tensions worsening day by day, Garfield met with Keene at the Mark Hopkins Hotel in San Francisco and asked him to turn around the organization. It took Keene 15 years to realize that Kaiser had forced Garfield to ask Keene to become his replacement. Due to the chaos on the board, Keene at first took control with the vague title of Executive Associate, but it soon became clear to everyone that he was actually in charge and Garfield was to become a lobbyist and "ambassador" for the HMO concept.[32]

However, even with Garfield relieved of day-to-day management duties, the underlying problem of Henry Kaiser's authoritarian management style continued to persist. After several tense confrontations between Kaiser and Permanente Medical Group physicians, the doctors met with Kaiser's top adviser, Eugene Trefethen, at Kaiser's personal estate near Lake Tahoe on July 12, 1955. Trefethen came up with the idea of a contract between the medical groups and the health plans and hospital foundations which would set out roles, responsibilities, and financial distribution.[33] Trefethen, already a successful attorney, went on to a successful career with Kaiser Permanente and in retirement became a famous vintner.

While Keene and Trefethen struggled to fix the damage from Kaiser's micromanagement and Garfield's ineffectual management, Henry Kaiser moved to Oahu in 1956 and insisted on expanding Kaiser Permanente into Hawaii in 1958. He quickly ruined what should have been a simple project, and only a last-minute intervention by Keene and Trefethen in August 1960 prevented the total disintegration of the Hawaii organization.[34] By that year, Kaiser membership had grown to 808,000.[35]

Managed care era[edit]

Having overseen Kaiser Permanente's successful transformation from Henry Kaiser's healthcare experiment into a large-scale self-sustaining enterprise, Keene retired in 1975.[36] By 1976, membership reached three million. In 1977, all six of Kaiser Permanente's regions had become federally qualified health maintenance organizations. Historians now believe then-President Richard Nixon specifically had Kaiser Permanente in mind when he signed the Health Maintenance Organization Act of 1973, as the organization was mentioned in an Oval Office discussion of the Act, where John Ehrlichman characterized Kaiser's philosophy thus: "All the incentives are toward less medical care, because the less care they give them, the more money they make."[37] In 1980, Kaiser acquired a non-profit group practice to create its Mid-Atlantic region, encompassing the District of Columbia, Maryland, and Virginia. In 1985, Kaiser Permanente expanded to Georgia.

Regional evolution[edit]

By 1990, Kaiser Permanente provided coverage for about a third of the population of the cities of San Francisco and Oakland; total Northern California membership was over 2.4 million.[38]

Elsewhere, Kaiser Permanente did not do as well, and its geographic footprint changed significantly in the 1990s. The organization spun off or closed outposts in Texas, North Carolina, and the Northeast. In 1998, Kaiser Permanente sold its Texas operations, where reported problems had become so severe that the organization directed its lawyers to attempt to block the release of a Texas Department of Insurance report. This prompted the state attorney general to threaten to revoke the organization's license.[39] Kaiser Permanente closed health plans in Charlotte and Raleigh-Durham[40] in North Carolina four years later. The organization also sold its unprofitable Northeast division in 2000. The Ohio division was sold to Catholic Health Partners in 2013.[41]

In 1995, Kaiser Permanente celebrated its fiftieth anniversary as a public health plan. Two years later, national membership reached nine million. In 1997, the organization established an agreement with the AFL-CIO to explore a new approach to the relationship between management and labor, known as the Labor Management Partnership. Going into the new millennium, competition in the managed care market increased dramatically, raising new concerns . The Southern California Permanente Medical Group saw declining rates of new members as other managed care groups, notably HealthCare Partners, flourished.

KP HealthConnect[edit]

In 2002, Kaiser Permanente abandoned its attempt to build its own clinical information system with IBM, writing-off some $452 million in software assets. This information technology failure led to major changes in the organization's approach to digital records. Under George Halvorson's direction, Kaiser looked closely at two medical software vendors, Cerner and Epic Systems, ultimately selecting Epic as the primary vendor for a new system, branded KP HealthConnect. Although Kaiser's approach shifted to "buy, not build," the project was unprecedented for a civilian system in size and scope. Deployed across all eight regions over six years and at a cost of more than $6 billion,[42] by 2010, it was the largest civilian electronic medical record system, serving more than 8.6 million Kaiser Permanente members, implemented at a cost exceeding a half million dollars per physician.[43]

Military and Veterans[edit]

Kaiser Permanente is dedicated to hiring more veterans and launched a new resource to recruit top military talent into the organization. The Military Landing Page on the Kaiser Permanente Careers Website launched on September 17, 2014.[44] Dr. Ronald Copeland, formerly a Major in the United States Air Force Medical Corps, elevated this program to the national level through his work as Senior Vice President and Chief Diversity and Inclusion Officer of Kaiser Permanente. Kaiser Permanente recognizes the work ethic, dedication, and initiative as traits in our military service men and women and looks forward to welcoming these unique skills and experience to the KP workforce. Additionally, Kaiser Permanente has launched a Junior Military Officer (JMO) Program. The JMO Program underscores KP's dedication to hiring and supporting the professional advancement of men and women in the armed forces is the JMO Program.

This unique two-year rotational program prepares high-performing military officers for leadership roles with us. The program includes challenging work experience, leadership mentoring, and formal Web-based and classroom training. You’ll cultivate the skills you need to be a successful leader and get experience in a broad number of business areas, including but not limited to; Information Technology, Enterprise Shared Services, National Facilities Services, Care Management Institute, Health Care Administration, and Human Resources. KP relies on the success of our leaders to help us advance our cause, and we’re proud to count our service men and women among them. If you’re interested in a leadership role with us, consider participating in our JMO Program. The recruiting for the JMO Program begins in 2015.

Since Kaiser's inception the organization has worked to support the military and veterans of the United States Armed Forces. The Department of Veterans Affairs (VA) and Kaiser Permanente launched a pilot medical data exchange program in San Diego using the Nationwide Health Information Network in 2010.[45]

The medical data exchange program enables clinicians from Kaiser Permanente and the US Department of Veterans Affairs (VA) obtain war veterans electronic health record information. President Obama's cabinet member representing US Veterans stated, "The Department of Veterans Affairs and the entire administration are encouraged by the opportunities that electronic health record interoperability provides for Veterans, Service Members and their dependents ... . We are proud to join in this effort with Kaiser Permanente and to achieve the benefits of health data exchange, including improved quality, patient safety, and efficiency." Reports state that over half of US war veterans and active-duty service members receive health care outside of VA and/or Department of Defense facilities.

International reputation[edit]

Early in the 21st century the NHS and UK Department of Health became impressed with some aspects of the Kaiser operation, and initiated a series of studies involving several healthcare organisations in England.[46][47] Visits occurred and suggestions of adopting some KP policies are currently active. The management of hospital bed-occupancy by KP, by means of integrated management in and out of hospital and monitoring progress against care pathways has given rise to trials of similar techniques in eight areas of the UK.

In 2002, a controversial study by California-based academics published in the British Medical Journal compared Kaiser to the British National Health Service, finding Kaiser to be superior in several respects.[46] Subsequently, a group of health policy academics who were experts on the NHS published a competing analysis claiming that Kaiser's costs were actually substantially higher than the NHS and for a younger and healthier population.[48]

Quality of care[edit]

In the California Healthcare Quality Report Card 2013 Edition, Kaiser Permanente's Northern California and Southern California regions, Kaiser received four out of four possible stars in Meeting National Standards of Care. Kaiser North and South also received three out of four stars in Members Rate Their HMO.[49]

U.S. News and World Report, in its 2006 annual ranking of US commercial health plans, ranked Kaiser Foundation Health Plans as follows, out of 246 rated plans:[50]

  • 45. Northern California
  • 57. Colorado
  • 65. Georgia
  • 67. Ohio
  • 90. Southern California
  • 94. Hawaii
  • 106. Mid-Atlantic States
  • 121. Northwest

A 2004 Consumer Reports survey of planholders ranked Kaiser Permanente overall as average or better. It showed below average ratings in the Colorado and Mid-Atlantic regions for two measures of quality of care: 'care from doctors', and the 'quality of their primary care physician'. The same survey ranked Kaiser Permanente's Northern California region as the best HMO overall among rated plans.[51]

KP's performance has been attributed to three practices: First, KP places a strong emphasis on preventive care, reducing costs later on. Second, its doctors are salaried rather than paid per service, which removes the main incentive for doctors to perform unnecessary procedures. Thirdly, KP attempts to minimize the time patients spend in high-cost hospitals by carefully planning their stay and by shifting care to outpatient clinics. This practice results in lower costs per member, cost savings for KP and greater doctor attention to patients. A comparison to the UK's National Health Service found that patients spend 2–5 times as much time in NHS hospitals as compared to KP hospitals.[52]

Their habits of offering preventive care and managing chronic disease led a journalist writing for The New York Times to propose the Kaiser system in 2004 as a model for U.S. healthcare.[53]

Research and publishing[edit]

Kaiser doctors and others carry out research publishing in peer-reviewed journals and in the organization's own peer-reviewed journal The Permanente Journal.

Kaiser operates a Division of Research, which annually conducts between 200 and 300 studies, and the Center for Health Research which in 2009 had more than 300 active studies. Kaiser's bias toward prevention is reflected in the areas of interest—vaccine and genetic studies are prominent. The work is funded primarily by federal, state, and other outside (non-Kaiser) institutions.[54]

Measles vaccine project participation[edit]

Between June 1990 and October 1991, Kaiser, along with the Los Angeles County Department of Health, Johns Hopkins University and the CDC carried out a clinical trial of the Edmonton strain of Measles vaccine. The Los Angeles arm of the trial involved 1500 (900 receiving the study treatment) mostly black and Latino babies. Other arms ran in Haiti and several African countries. The aim was to induce immunity to measles earlier, as cases in young children had been causing alarm. The trial was ended early when increased mortality appeared in other countries. Inadequate consent had been obtained, in that parents were not informed that the vaccine, licenced in other countries and registered with the FDA as a trial medication, was unlicensed in the U.S. This raised concerns over U.S. government department ethics, and occasioned an apology by the CDC who ascribed it to an administrative oversight.[55]


In California, the Department of Managed Health Care is the state regulatory agency which oversees managed care insurers and providers. In 2013, the Department of Managed Health Care ranked Kaiser Permanente near the top of the list of California managed care insurers,[49] and rated the health plan as superior on preventive care. Patients in California are restricted in their legal agreement upon membership to resolve complaints related to quality of care through binding arbitration.

Federal regulation of managed care[edit]

The organization is mentioned in an Oval Office discussion about the initiation[56] of the Health Maintenance Organization Act of 1973. By 1977, all six of Kaiser's regions had become federally qualified HMOs.

Concerns and violations[edit]

In recent years, the organization has come under scrutiny for management, patient care, financial and technology issues, primarily in its Northern and Southern California regions.

Grossly Inadequate Mental Health Care[edit]

In June 2013, the California Department of Managed Health Care levied a $4 million fine against Kaiser for not providing adequate health care to its customers. Alleged violations of California's timely access laws included failures to accurately track wait times and track doctor availability amid evidence of inconsistent electronic and paper records that may indicate an effort by Kaiser to conceal lengthy wait times. It was also found by the DMHC that patients received written materials circulated by Kaiser dissuading them from seeking care, a violation of state and federal laws. "The Department's actions are a result of both the seriousness of the deficiencies and the failure of Kaiser to promptly correct them," said DMHC Director Brent Barnhart in a press release announcing the fine.[57]

In September 2014, Kaiser withdrew an appeal and paid the $4 million after maintaining for a year that they were involved in no wrongdoing. Judge Ruth Astle rejected a portion Kaiser's document evidence and questioned the ethics of Kaiser's expert witness and council—a former DMHC prosecutor turned private defender of HMOs facing regulatory penalties.[58]

Over the course of the year the following additional violations were reported:[58]

• As of September 2014, pediatric psychiatric patients waited up to 22 weeks before receiving a phone call from Kaiser's San Francisco psychiatry department to schedule an appointment, according to Kaiser's records.

• In August 2014, Kaiser's psychiatry department was unable to respond to dozens of voice mails from new patients due to staffing issues for more over a week.

• In July 2014, Kaiser instructed employees in at least one clinic to falsify appointment records rather than provide patients with urgent appointments within 48 hours, as mandated by state law.

• In May 2014, Kaiser failed to provide timely mental health appointments to more than 60 percent of the patients seeking care at Kaiser's Oakland and Richmond facilities, according to data supplied by Kaiser.

• In April 2014, one of Kaiser's Southern California clinics required patients with acute conditions—including auditory hallucinations—to wait more than seven weeks for an appointment.

In January 2015, Kaiser health care employees began striking after claiming that Kaiser did not staff its clinics appropriately following the DMHC review and fine, and purportedly directed staff to instead attend to new patients primarily. After an initial appointment for diagnosis, Kaiser patients were made to wait weeks or months for follow-up appointments. On Jan 2, 2015, in anticipation of the tens of thousands of new patients coming into the Kaiser system following 2014 open enrollment, Kaiser's Fremont, CA psychiatry department ordered its clinicians to delay all non-urgent patients well beyond the legal ten-day waiting period, and they closed their Intensive Outpatient Program to new patients.[59]

Mandatory arbitration[edit]

In order to contain costs, Kaiser requires agreement by planholders to submit patient malpractice claims to arbitration rather than litigating through the court system. This has triggered some opposition.[42]

Wilfredo Engalla is a notable case. In 1991, Engalla died of lung cancer nearly five months after submitting a written demand for arbitration. The California Supreme Court found[60] that Kaiser had a financial incentive to wait until after Engalla died; his spouse could recover $500,000 from Kaiser if the case was arbitrated while he was alive, but only $250,000 after he died. The Foundation for Taxpayer and Consumer Rights contends that Kaiser continues to oppose HMO arbitration reform.[61]

Watchdogs have accused Kaiser of abusing the power imbalance inherent in the arbitration system. Kaiser engages in many cases whereas a customer will usually engage in just one and Kaiser can reject any arbitrator unilaterally, thus they can select company-friendly arbitrators over those that rule in favor of customers. As a large organization, Kaiser can also afford to spend much more on lawyers and orators than the customer, giving them more advantages. In response to criticisms, Kaiser established an Office of Independent Administrators (OIA) in 1999 to oversee the arbitration process. The degree to which this is independent has been questioned.[62]

Patients and consumer interest groups sporadically attempt to bring lawsuits against Kaiser Permanente. Recent lawsuits include Gary Rushford's 1999 attempt to use proof of a physician lie to overturn an arbitration decision.[63]

In one case, Kaiser attempted to significantly expand the scope of its arbitration agreements by arguing it should be able to force nonsignatories to its member contracts into arbitration, merely because those third parties had allegedly caused an injury to a Kaiser member which Kaiser had then allegedly exacerbated through its medical malpractice. The California Court of Appeal for the First District did not accept that argument: "Absent a written agreement—or a preexisting relationship or authority to contract for another that might substitute for an arbitration agreement—courts sitting in equity may not compel third party nonsignatories to arbitrate their disputes."[64]

Patient dumping[edit]

Kaiser has settled five cases for alleged patient dumping—the delivery of homeless hospitalized patients to other agencies or organizations in order to avoid expensive medical care—between 2002 and 2005. During that same period, the Department of Health and Human Services' Office of the Inspector General settled 102 cases against U.S. hospitals which resulted in a monetary payment to the agency.[65][66]

On November 16, 2006, Los Angeles city officials filed civil and criminal legal action against Kaiser Permanente for patient dumping as reported by National Public Radio's All Things Considered.

The city's decision to charge Kaiser Permanente reportedly was influenced by security camera footage, allegedly showing a 63-year-old patient, dressed in hospital gown and slippers, wandering toward a mission on Skid Row, as outlined in a 20-page complaint. City officials say that as many as 10 other area hospitals are under investigation for possible future action for this practice.[67]

Kidney transplant program violations lead to closure[edit]

In 2004, Northern California Kaiser Permanente initiated an in-house program for kidney transplantation. Prior to opening the transplant center, Northern California Kaiser patients would generally receive transplants at medical centers associated with the University of California (UC San Francisco and UC Davis). Upon opening the transplant center, Kaiser required that members who are transplant candidates in Northern California obtain services exclusively through its internal KP-owned transplant center.

On May 3, 2006, the Los Angeles Times published an investigative report which showed across-the-board mismanagement in the KP-run transplant program which resulted in delays for patients awaiting kidneys.[68] According to the report, Northern California Kaiser performed 56 transplants in 2005 and twice that many patients died waiting for a kidney. At other California transplant centers, more than twice as many people received kidneys than died during the same period. The practice of delaying these transplants resulted in considerable savings for KP.

On May 13, 2006, after less than two years of operation, Northern California Kaiser announced it would discontinue the kidney transplant program. As before, Northern California Kaiser now pays for pre-transplant care and transplants at outside hospitals who have proven they are competent in providing this care. This change affected approximately 2,000 patients.[69][70]

Two patients have filed personal injury lawsuits against Kaiser and the widow of a patient who died has filed a wrongful death claim. According to the lawyer representing the three plaintiffs, more lawsuits are planned.[71]

Labor unions[edit]

While Doctors of Medicine (M.D.) and Doctors of Osteopathic Medicine (D.O.) are partners within the for-profit physician groups, many employees are members of various unions and guilds, depending on their role and service area.

KP's California operations were the target of four labor strikes in 2011 and 2012, two (Sept 2011 and Jan 2012) involved more than 20,000 nurses, mental health providers, and other professionals.[72] The National Union of Healthcare Workers (NUHW) has accused Kaiser of deliberately stalling negotiations while profiting $2.1 billion in 2011 and paying its CEO George Halvorson $9 million annually. The workers have complained of poor staffing, delayed care, and loss of pensions, medical insurance, and other benefits.[73]

On 11 November 2014, up to 18,000 nurses went on strike at KP hospitals in Northern California over Ebola safeguards and patient-care standards during union contract talks. 21 hospitals and 35 clinics in the San Francisco Bay Area were affected.[74]


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External links[edit]