Saturday, December 18, 2010

NHS-Kaiser Permanente: Which Bits?

For some years, successive governments have been verbal in hailing Kaiser Permanente as the model for a future NHS, and it is an open secret that Kaiser Permanente has been visited by many PCT and NHS Trust members.  Bearing in mind this trend, we need to look closely at Kaiser Permanente’s claims and indeed look at the lessons that can be learned, the “bits” that are applicable and the “bits” that are not.  The once progressive Royal College of Physicians in England seems to agree: David Lawrence, Kaiser's chief executive, gave a talk there entitled:
"Can the NHS Learn From the USA?"

So what indeed can we learn?
©2010 Am Ang Zhang

Importing the US model will undermine the health service

What the NHS can learn from the US is that its healthcare system is in crisis. The US healthcare industry is big business, but the 40 million poor, including 10 million children, have no insurance. Healthcare bills result in 40% of personal bankruptcies annually.

Health Insurers until now exclude pre-existing conditions. This means the sickest and especially the chronically ill will not get coverage. Additionally by a process called:


When a person is diagnosed with an expensive condition such as cancer, some insurance companies review his/her initial health status questionnaire. In most states’ individual insurance market, insurance companies can retroactively cancel the entire policy if any condition was missed – even if the medical condition is unrelated, and even if the person was not aware of the condition at the time. Coverage can also be revoked for all members of a family, even if only one family member failed to disclose a medical condition.

The government and Kaiser may well argue that its not-for-profit status engenders different behaviour. But in the US, the not-for-profits use the same tactics as the for-profits when the environment gets competitive. Kaiser actively seeks younger, healthier members and imposes different rates for employer groups based on their history and risk of healthcare.

Sometimes their competitive behaviour gets them into trouble. The California branch of Kaiser has had cumulative fines of $1.6m, 63% of all the fines levied by the Californian department of managed healthcare. The activities for which they have been fined include denial of care, use of unqualified staff and inadequate staff-patient ratios.

In Britain, the government argues that it does not matter who provides health services so long as they remain publicly funded. But the crisis-ridden US healthcare industry is also heavily dependent on government funding and there are striking similarities between its model of health maintenance organisations (of which Kaiser is one example) and Britain's primary care trusts, which replaced district health authorities in April and which will hold 70% of the NHS budget.
American health maintenance organisations integrate insurer (funding) and provider functions, rather like Bupa or PPP healthcare. This builds in an incentive to pass the risks and costs of care down to the patient. Primary care trusts also integrate funding and provider functions and are established as trading bodies or business units. Their statutory duties require them to break even and when there is insufficient funding they must find more income or pass risk back to patients.
There are four ways of doing this: excluding high-risk groups; limiting the range of services; redefining some NHS care as non-NHS care; and income generation through private healthcare. The first option is difficult since primary care trusts can't actively exclude high-risk and high-cost individuals, but they will have a strong incentive to restrict the services available to groups such as the mentally ill and those with chronic disease.

Primary care trusts may also seek to redefine NHS care as personal care by implementing Department of Health guidance issued last year which recommends limiting NHS care to a maximum of six weeks. Primary care trusts could use this to redefine elements of NHS care as personal care (rehabilitation after a stroke, say), which would then be subject to means testing and patient charges.
There is nothing to stop primary care trusts promoting the use of private insurance and sale of top-up services to NHS patients. A recent BMJ article which purported to show that Kaiser delivered cheaper healthcare at higher quality has been discredited. The NHS provides cover to all 60 million residents but Kaiser California covers fewer than 6.1 million of the 34 million in California and excludes the 20% uninsured. Even so, Kaiser's crude costs are more than 40% higher per capita than the NHS. Healthcare costs rise while access and quality fall when private providers come on the scene.

The government's modernisation plans for the NHS have all the hallmarks of the US model in which the government devolves the risks and costs of care to doctor and patient. The success of the NHS has been due to its dual role as universal payer and provider. If the government persists in uncoupling this by importing US models of care, they will import the US care crisis and all the inequities which follow.

The article was written by Allyson Pollock
The Guardian, Friday 21 June 2002 11.00 BST

Yes!!! 2002
Professor Allyson Pollock was then head of health policy at University College London. She has now moved to Scotland.    

Kaiser Permenente money saving tactics:

Mental & Chronic Illness:
In some plans Kaiser does not provide care for chronic serious mental illness, care of the elderly is variable, and some care, such as that for a chronic illness, ceases altogether after 100 days.

Patient dumping:
November 16, 2006
The Los Angeles city attorney's office has filed criminal charges against hospital giant Kaiser Permanente for endangering a former patient. The charges allege Kaiser dumped a homeless patient on the city's downtown Skid Row.

The charges stem from video captured by security cameras in March. The footage shows a 63-year-old patient from Kaiser Permanente's Bellflower hospital, dressed in a hospital gown and 

Union Rescue Mission                                      slippers, exiting a taxicab on Skid Row. She is later seen shuffling toward the Union Rescue Mission, the city's largest homeless shelter.

NPR   LA Times
At least she was near a homeless shelter, unlike others we know about in Mid Staffordshire.

Kidney transplant program violations lead to closure

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. 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.[66] 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.

Read more>>>>

Mandatory arbitration

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 discussion and dissent. Some cases proceed to court and one argument is over whether the requirement to go through dispute resolution is enforceable.

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 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 & Consumer Rights contends that Kaiser continues to oppose HMO arbitration reform.

Read more>>>>
On January 1, 2014, health insurance carriers will no longer be able to deny coverage for pre-existing health conditions. However, for many with pre-existing health conditions this is simply too long to wait to get California health insurance coverage. Perhaps, they are unable to qualify for group insurance and they would be denied if they applied for an individual health insurance plan. Help is on the way. As of this September 23, 2010, health insurance carriers will no longer be able to deny coverage to minors ages 18 and under. Also, for those 19 and above, states will be offering Pre-Existing Condition Insurance Plans (PCIP) beginning this August, 2010.

Kaiser Permanente declined an invitation to join the Plan:

"To meet the law’s rapid deadlines, the state of California understandably opted to use a financial intermediary (third-party administrator) to make fee-for-service payments to healthcare providers," said Trish Doherty, a spokeswoman for Kaiser. "As a predominantly prepaid healthcare provider, Kaiser Permanente is not organized in a manner that allows us to easily participate in this new program."

Many other states had something similar. By 2014 no insurer will be allowed to exclude anyone. That was the Obama reform. We will have to wait and see what happens and perhaps it is why so many insurers are coming to England.

Ranking in California:
In 2003 the California Institute for Health Systems Performance published a consumer guide ranking the quality of care in 181 hospitals across California. The score was based on the recent hospital experiences of 35 000 patients, and included a survey of patients' experiences with respect to patient preferences, coordination of care, information and education, physical comfort, emotional support, involvement of family and friends, and transition to home. Kaiser accounted for 27 hospitals out of the 181 surveyed, and 11 of them were rated below average for quality of care, whereas the remainder were only rated average.

So which “bits” can NHS implement?!!!

NY Times:
HEALTH care systems in most industrialized countries are in crises of one form or another. But the American system is characterized by both feast and famine: it leads the world in delivering high-tech medical miracles but leaves 45 million people uninsured. The United States spends more on health care than any other country - $6,167 a person a year - yet it is a laggard among wealthy nations under basic health measures like life expectancy. In a nutshell, America's health care system, according to many experts, is a nonsystem. "It's like the worst market system you could devise, just a mess," said Neelam Sekhri, a health policy specialist at the World Health Organization in Geneva.
The Last words:

Prof Allyson Pollock and Sir Denis Pereira Gray:
“When the Lancet published a paper on MMR, which threatened to undermine public health programmes, the DH and other major medical journals lost no time in entering into the scientific debate. Now we have a paper being widely adopted by policy makers, the claims of which concerning Kaiser are not supported by the evidence.”

Guardian: Allyson Pollock
Additional material: Wikipedia


Anonymous said...

It is not a joke anymore. NHS is being privatised. GP commissioning is a means to limit cost and place the blame on GPs. Most consultants will go private and that is the scary bit.

There is too little in the press about the latter.

Sample Survey Questionnaire said...

Hello guys, what do u mean by NHS?

Anonymous said...

NHS-National Health Service. UK. Or is it just England now!!!