In mid-2004, more than 1,500 Kaiser Permanente patients awaiting kidney transplants in Northern California got form letters that forced them to change the course of their treatment.
Kaiser would no longer pay for transplants at outside hospitals, even established programs with thousands of successes. Instead, adult patients would be transferred to a new transplant center run by Kaiser itself -- the first ever opened by the nation's largest HMO.
Within months after Kaiser's kidney program in San Francisco started up, its waiting list ranked among the longest in the country. No other center had ever put together such a list so fast.
The patients didn't know it, but their odds of getting a kidney had plummeted.
Kaiser's massive rollout in Northern California endangered patients, forcing them into a fledgling program unprepared to handle the caseload, according to a Times investigation based on statistical analyses, confidential documents and dozens of interviews.
Hundreds of patients were stuck in transplant limbo for months because Kaiser failed to properly handle paperwork. Meanwhile, doctors attempting to build a record of success shied away from riskier organs and patients, slowing the rate of transplants performed.
National transplant regulators apparently did not notice the program's failures, though some were obvious in the statistics the regulators themselves posted on the Internet.
In 2005, the program's first full year, Kaiser performed only 56 transplants, while twice that many people on the waiting list died, according to a Times analysis of national transplant statistics.
At transplant centers statewide, the pattern was the reverse: More than twice as many people received kidneys than died.
Kaiser also suffered by comparison to the two outside hospitals that previously had tended to its Northern California patients. In each of the two years before Kaiser opened its program, UC San Francisco and UC Davis medical centers together performed at least 168 transplants on Kaiser patients, three times as many as Kaiser managed in its first full year.
"If they couldn't handle as many as they were doing before, they should have just transferred some" patients, said Neva Smith, whose daughter, Alison Bertino, was moved to Kaiser from UC San Francisco.
Bertino, 30, died last June while waiting for a kidney.
It is difficult to say whether she or any other Kaiser patients died as a direct result of the program's faltering start. What is clear is that many fewer patients received transplants than before, forcing them to remain on grueling sessions of dialysis to remove impurities from their blood. Prolonged dialysis can lead to deadly complications and decrease the chances of a successful transplant later.
The problems at Kaiser went beyond mere growing pains, current and former employees said: Surgeons and kidney specialists battled over who should receive transplants. Desperate patients complained of inexplicable delays. Since the program opened, 10 permanent employees have quit or been fired out of a staff of 22.
"On the outside, the program seems to have settled into a reasonably functioning unit," kidney specialist Dr. W. James Chon wrote to the hospital's physician-in-chief Jan. 23, not long before he was placed on administrative leave.
"However, a closer look at the program will show that it is suffering from very serious and potentially explosive problems," he said.
In interviews with The Times, Kaiser officials initially denied that there were problems. "Everything has been going on track," head transplant surgeon Arturo Martinez said last week.
Since then, other officials have acknowledged that the program had provided The Times with incomplete or misleading information. The chief physician at Kaiser's main San Francisco hospital conceded that the issues were "very serious."
"Time will tell whether 'explosive' was an appropriate adjective or not," said Dr. Bruce Blumberg, referring to Chon's letter.
But, he said, the problems have not affected care for the patients on the waiting list, now totaling about 2,000. No patients have died after transplants, and surgeons hope to boost their output to about 90 transplants this year, Blumberg said.
"I'm very pleased at the work done by the transplant program in the first year," he said.
Kaiser's troubled launch -- coming to light after scandals forced the closure of two transplant programs in Southern California last year -- underscores the dearth of oversight in the field of transplantation.
Leaders of the United Network for Organ Sharing, the federally funded group responsible for the nation's organ transplant system, said they knew nothing of Kaiser's woes until The Times contacted them.
Dr. Andrew Klein, director of transplant programs at Cedars-Sinai Medical Center in Los Angeles and a member of the network's board, said moving patients to new centers should never compromise the care they receive.