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Kaiser Made It Hard to See an MD, Critics Say

Health: HMO hindered Northern California patients' access to doctors, papers show. But service is better of late, a top physician says.


Kaiser Permanente, the largest HMO in California, presented two very different faces in the late 1990s.

Publicly, it promoted itself in an advertising campaign as a health maintenance organization whose patients were "in the hands of doctors."

Privately, according to internal documents, Kaiser was making it difficult for its Northern California patients to see doctors.

The documents, largely minutes of private meetings and doctors' e-mails, highlight a Kaiser culture that for years equated managing care with making it inconvenient to get.

The papers, obtained by The Times from a union and a consumer group, provide a rare glimpse into the inner workings of an HMO as it struggles to attract and retain customers in one of the most competitive health care marketplaces in the country.

One of the most striking of the documents describes the Northern California operation's long-standing practice of making patients wait for doctors' appointments to save money and "control demand."

Dr. Robert Pearl, chief executive of the physician group that treats 3 million Kaiser patients in Northern California, candidly described how "we chose not to provide our patients with what they desired," according to minutes of a private meeting last spring.

At a meeting last summer, Pearl told his physician group's board of directors that this way of doing business had left patients and doctors dissatisfied--and wasn't saving money. He said it was time to change.

In a recent interview with The Times, Pearl said Kaiser had become a leader in improving patient access. But that, internal documents suggest, meant breaking with the past.

Using 'Wait Lists' to Control Demand

"Historically," Pearl told the Permanente Group board, according to the minutes of a July 2000 meeting, "we believed that making patients wait for a routine primary care appointment was less costly and would lower utilization. . . .

"[W]e believed that wait lists for specialty consultation were the best means to control demand.

"[W]e also believed that, if we were to supply enough urgent care appointments to match expected demand, that demand would only increase and we would again be short of appointments."

But, Pearl said, those assumptions proved wrong. No money was saved, in part because the vast majority of patients persisted until they got past a cumbersome telephonic triage system that stood between them and their doctors. Most got appointments on the same day they sought them. All who persisted, Pearl said, were eventually seen.

Not only did the approach fail to discourage large numbers of patients, Pearl said, it also was inconsistent with a Kaiser's new long-term business strategy. In the mid- and late 1990s, the HMO began seeking to reposition itself in the marketplace as a high-end HMO with the goal of becoming a "leader in quality and service."

"This will be a challenge for us, given that historically we have been viewed as low-cost, low-service and often low-quality," he said.

The repositioning was the result of a long self-examination by Kaiser that involved focus groups and marketing consultants and led to a national advertising campaign in 1998.

The crux of the campaign was a claim that Kaiser was distinctive because its patients--unlike patients in other HMOs--were "in the hands of doctors." The main idea was that Kaiser doctors could decide which treatments to provide without having to get clearance from insurance company bureaucrats.

Some patients and a consumer group, the Foundation for Taxpayer and Consumer Rights, took issue with the claim, alleging in a lawsuit that Kaiser doctors' treatment decisions are also financially motivated. The suit is pending.

But the slogan struck some Kaiser employees as problematic for other reasons.

At the same time that the "in the hands of doctors" slogan was being launched, Kaiser officials were redesigning their approach to patient care in Northern California to emphasize increased use of non-doctors.

A Kaiser official who was involved in designing the new approach expressed the worry in a 1998 e-mail that the greater reliance on non-doctors did not square with the slogan. The official, Cecilia Runkle, fretted that "members are currently having difficulties getting timely access to their physicians."

"The tag line may promise more than we can deliver," she wrote to a Kaiser official involved in the advertising effort.

Runkle's e-mail was turned over to the consumer group in the course of its lawsuit, which alleges that Kaiser engaged in illegal false advertising.

Kaiser denies it was misleading anyone and cites, as evidence, an independently conducted consumer survey showing that its Northern California members rated Kaiser above average in the late 1990s in terms of access to care when compared to other major managed care plans. Southern California members rated Kaiser's accessibility about average.

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