16 May 2018

About Kaiser Permanente

I get my health insurance through an Obamacare Kaiser Permanente plan.

Kaiser gets a bad rap in word of mouth reviews, but on the whole, I feel good about this choice.

The Business Model

There are a lot of things that Kaiser does right, and these things, as well as its faults, have a lot to do with its unique vertically integrated system. 

Kaiser is both a health insurer and a health care provider. Except for emergency room care and possibly a few kinds of national specialty care that it can't maintain in network, all medical care is provided by Kaiser employees in Kaiser' owned and run facilities.

Kaiser is a secular non-profit organization.

Kaiser's medical professionals there are employees and not entrepreneurs. Kaiser's administrators are people trained to manage medical operations, not doctors trying to carry out administrative tasks they weren't taught in medical school. Kaiser's ability to let medical professionals be medical professionals and not have to deal with anything else allows them to pay lower salaries for comparably skilled professionals.

Kaiser centralizes its provision of health care in a small number of large, hospital scale facilities that are run like an airport complete with check in kiosks, long walks to where you need to go within a complex of buildings, and connected parking complexes.



For comparable levels of insurance coverage, Kaiser is the lowest priced, which is why Kaiser is almost always number one in market share within markets where it is an Obamacare marketplace option. This is mostly due to streamlined billing and record keeping processes, due to paying doctors less since they don't have to deal with business management issues, due to better administrative management, due to a lack of a need to earn profits, and due to economies of scale by providing health care on a centralized basis to a large patient base. 

So, the lower price of Kaiser health insurance premiums does not come from covering less or providing lower quality care, as is the case in other low priced health insurance plans (coupled with price conscious medical provider shopping in deductible plans).

It is also easy to pay the premiums over the phone or Internet, 24/7.

Billing For Services Provided

With any other health insurer, billing issues between providers and insurers are a constant back and forth battle. Billing screw ups are common. Anything as complex as a child birth or minor surgery almost inevitably requires time consuming and stressful work with the triangle of provider-insurance company and you to sort out at least one or two problems. And, there isn't just one provider to deal with - ever doctor, paraprofessional, material provider and non-professional service provider involved sends a separate bill with the bills for a single medical procedure often coming in over a matter of months in multiple separate mailings with no way to know if you've actually received all of them. The discrepancy between the "sticker price" and the price your insurance company actually allows is absurd and a misstep in the process means you get stuck with being billed the "sticker price" which is paid only by uninsured people who don't have the time to negotiate in advance and can' pay cash. Usually, the human being providing the services and the patient have no idea what the sticker price or insurance price will actually be until long after the services have been provided.

With Kaiser, that simple doesn't happen. There is never an insurance company-provider billing dispute. In the HMO plan that I choose, 90%+ of the services that I receive have a fixed, reasonable co-payment that I know in advance and pay for in advance. When there is a deductible, there are no outrageous sticker prices to worry about - the price is on a standard, not inflated schedule. I get all of my bills from one office and I only have to deal with one office if there is a problem.

Good Systems

Research has consistently shown that good systems are as important to quality of health care as talented professionals providing care. Kaiser's centralized record keeping does a good job of making sure that you get the preventative and follow up care that you need with checklists, and of making sure that everyone in the team of medical providers has access to all of the relevant information about you.

The coordination between physicians, pharmacists, physical therapists, laboratories for medical tests, and the like within the system is nearly seamless. You can walk out of a doctor's visit and get many tests done immediately and pick up prescriptions all on the same trip.

Kaiser has quality control safeguards to monitors the working of systems that other providers don't even put in place, let alone carefully review.

Vetting and Quality Control of Medical Professionals.

The actual medical professional at Kaiser are for the most part, no better and no worse than those available through traditional preferred provider networks in an ordinary health insurance plan. 

But, since many medical professionals are independent, self-employed contractors, Kaiser also provides a means of vetting medical professionals to keep out the worse ones than an individual signing up doctors on their own, and the centralized locations of Kaiser facilities also provides a greater level of oversight for medical professionals that allows it to weed out medical professionals who see a deterioration in service quality due to personal issues much more quickly than an insurance company dealing with an independent private practice could.


Geographic and temporal availability of providers

The biggest disadvantage of Kaiser is that you can only use Kaiser run providers, except for emergencies. Obviously, there are good economic reasons for this to be the case. But still, it is a major drawback.

Kaiser Is In Only A Few States and Serves Only Some Metro Areas In Some Of Them

This means that Kaiser is pretty much useless outside the handful of metropolitan areas where it has provider centers set up around the country in half a dozen states, unless you need to go to an emergency room. For example, my daughter in Maine for college needed supplemental coverage  for non-emergency care because the closest Kaiser facility to her is in metropolitan Washington D.C.

Kaiser does not even seem to have reciprocity agreements so that if you are on vacation or visiting someone and need to fill a prescription or receive urgent care, you can't get meaningful insurance coverage for visiting an approved local provider somewhere where there aren't Kaiser facilities. This is effortless with pretty much any other health care provider.

It would not be very hard at all for Kaiser to have an agreement with one major national pharmacy chain like Walgreens or Kroger or Walmart or RiteAid, and one or two national urgent care clinic chains, to provide prescriptions and urgent care to Kaiser members in places outside the territory covered by Kaiser owned facilities for which Kaiser members would pay an increased out of network copay or deductible percentage, but prices would still be controlled. 

Indeed, an out of area urgent care agreement might actually save Kaiser money because often Kaiser members with no options other than going to an emergency room when out of area under the status quo could go to much less expensive urgent care centers instead.

Kaiser Has Only A Few Locations In Each Metropolitan Area

Unless a Kaiser provider location is close to you (they only have about three or four locations in the whole Denver metro area that provide a full set of services, and only one in Denver proper), getting to your provider appointments is inconvenient. The economies of scale here, are also obvious, but it is still a serious consideration.

For some services, like urgent care and mental health care providers, the situation is even worse because services aren't consistently available for all patients at all locations. 

For example, while Kaiser has two major provider offices adjacent to each other on the Presbyterian/Saint Luke's/St. Joseph's/National Jewish hospital complexes centered at about 20th Street and Franklin Street in Denver (which is its only Denver proper location), there are only about five psychiatrist at that location, some of which are only there part-time, who can't meet all of the demand from its usual service area, so someone in Denver needing a mental health care appointment needs to travel to a far South Denver facility near Parker, or to a facility in Aurora at about Alameda and Havana, which is a thirty to forty-five minute trip in good traffic and longer during rush hour. 

This is particularly irksome because a psychiatry office usually benefits much less from economies of scale (and indeed, neither of the two main metro Denver mental health offices are in the same building as Kaiser's non-mental health care services anyway). It would be very easy to set up a few more local mental health care clinics, but Kaiser hasn't done so. It wouldn't even be too difficult to set up specialty pharmacy clinics at those locations offering only meds that are typically prescribed by mental health professionals, rather than offering full service pharmacies. Or, for that matter, to have full service pharmacies at those locations to provide more local services.

The non-urgent care hours are quite limited, with no evening or weekend hours even though often someone just needs an after hours physician visit that doesn't call for the full capabilities of an urgent care clinic, and even the urgent care hours aren't great compared to other urgent care centers. The quality of care once you're there is fine, but can involve some significant wait time compared to the norm for urgent care. I have no idea why Kaiser doesn't have an urgent care facility at its large complex in Denver that sits empty on evenings and weekends. The capital costs would be minimal, and the number of medical professionals on site is large enough that with orderly rotations, professionals could do urgent care shifts just a few times a year and meet the demand. 

For a health care system with as many members as Kaiser has, there is really no excuse for not having at least one urgent care facility open in the metro area 24 hours a day, 7 days a week. There is also no good reason that Kaiser shouldn't offer some late night or weekend appointments for ordinary non-urgent care medical services when it operates at the scale that it does. Even if just 5% of ordinary primary care appointments could be scheduled in those hours, it would make a big difference to the utility of the services that they provide.

It is good that you can do very efficient single trips that combine lab tests or prescriptions order by the doctor minutes earlier, or can set up appointments in person or even the same day for physical therapy or other follow up care. But, it is inconvenient to have to pass half a dozen or more pharmacies en route to the closest Kaiser pharmacy on the way to fill your prescription.  There is a very long trip from anywhere in the metro area to Kaiser's one or two urgent care clinics (it doesn't even have a single urgent care clinic in Denver proper) sort of defeats the purpose of urgent care. If your looking for an after hours sports physical, that's tolerable. If you have a kid with a high fever or sprained ankle, the urge to stop at any of the dozens of free standing urgent care centers in the city even though it won't be covered is pretty intense.

Doctor choice

As a transition matter, having to leave your existing health care providers to transition to Kaiser providers is a pain. Once you've done it, however, it isn't that big a deal because your providers are in the system, and finding a new one when your doctor retires is easier. I haven't had any serious dissatisfaction with any of my providers at Kaiser, nor have any of my family members. And, I have met very few people who actually choose a doctor based on a real evaluation of the doctor's credentials rather than location and interpersonal issues and there are enough doctors in the Kaiser system to overcome interpersonal issues. It really isn't that different once you are in the system from having to chose providers within an insurance company's more ad hoc provider network.

The concern is greater, however, if you have a condition that requires really specialized care. For example, when my father had pancreatic cancer, his initial provider told him there was no hope and there was no cancer center in metropolitan Cincinnati willing to attempt the kind of surgery he ultimately received. He had to travel to Mayo Clinic in Rochester, Minnesota (which from a patient interface basis and administration perspective has a lot in common with Kaiser), where he got the treatment he needed and survived about a decade and a half afterwards with a condition that often kills you within six months of being diagnosed, and his insurance paid for almost all of those charges. I wouldn't have that option with Kaiser, at least without an epic bureaucratic fight for my life.

Systemic Limits On Care

I've heard that there are internal controls on what care will be offered by Kaiser that influence what its medical professionals will recommend that may rule out certain kinds of care that are less established or expensive. I suspect that this is true, although I haven't encountered it myself.

Insurance companies other than Kaiser also limit what they will cover, and network providers for insurance companies have incentive that work similarly, but most insurance policies cover out of network providers partially but significantly compared to network providers. And, the out of network coverage option in a traditional health insurance policy provides a patient to more access to care options that are discouraged or forbidden in a closed provider system like Kaiser.


While there are tradeoffs involved in using Kaiser over ordinary health insurance plans and network medical providers, on the whole, as someone who spends almost all of his time in metro Denver, the tradeoffs are well worth it.

Moreover, while I have some specific complaints about Kaiser, for the most part, this could be remedied with the kind of constructive solutions that I present in this post, making the gap between Kaiser and its competition much narrower.

1 comment:

Dave Barnes said...

Like Kaiser a lot.
Live 4 miles from Franklin.
My colon cancer treatment was excellent.
My perianal abscess care was excellent.

Hopefully no more "fix-it" visits for my old fart body.