Kaiser Made It Hard to See an MD, Critics Say

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.