By all accounts, Kaiser Permanente (a non-profit healthcare insurer and provider in the United States) is one of the best performing health care systems in the world.  Shouldn’t it follow then, that its health plan members fare better as a population in terms of their health status?  Not quite.

A few weeks ago, Kaiser Permanente was in Toronto to share their approach to health promotion and illness prevention.  We often look to leading health systems like Kaiser Permanente for inspiration, as they are years ahead of Canada in putting in place major innovations in their health care system, for example:

-  A fully integrated electronic health record for all 9 million plan members and their care providers actively use across several US states, as well as a personal health record that more than 60% of its members voluntarily access and use

-  More than 40% of primary care consultations occur via phone, e-mail or video consult, and rarely does a patient see their physician to receive a prescription.

-  All physicians are on salary, with a highly transparent performance management system that proactively alerts providers to gaps in their patients’ care profiles, and rank orders physicians against their peers against several key indicators

Indeed, across the 39 health care delivery indicators set out by a national healthcare quality council in the U.S.A., Kaiser Permanente’s health system is among the best performers, and is in 1st place for 11 of the 39 indicators.

If I were to ask whether Kaiser Permanente patients have superior health “outcomes”, the answer would be a resounding yes.   This is precisely what is reflected in those 39 quality indicators where Kaiser Permanente is a national leader.  Lower hospitalization rates. Fewer hospital re-admissions.  Better medication adherence. Earlier cancer screening and diagnosis. Fewer unnecessary tests.  That is, if you are a recipient of Kaiser Permanente’s health care services, you will have a superior experience and better clinical outcomes for less cost than most other health systems.

Yet despite the excellent medical care delivered by Kaiser, their members as a population are not necessarily any healthier than the non-Kaiser population, or even the uninsured population.

There were two key slides in their presentation that explained why this is so. The first was their up-front acknowledgement that only ~10% of population health is driven by the medical care that one receives (socioeconomic, environmental, behavioral and genetic factors making up the remaining 90%): 

Source: McGinnis et al, Health Affairs (2002)

The second was their validation of this theory with empirical data.  They presented a series of charts showing the geographic distribution of the incidence of risk factors for disease (obesity, hypertension) as well as disease (diabetes) amongst plan members in a state.  This one is shows the diabetes “hot spots” and “cold spots” by geography:

Diabetes in Bay Area

Two regions adjacent to each other displayed diametrically opposite rates of diabetes.  So what was the difference between these?  It wasn’t the quality of the health care system they were accessing – these maps show only Kaiser Permanente patients – patients in these two areas access the exact same high quality health care, at the same facilities, with the same robust tools and technologies that Ontario is currently investing heavily to put into place. Yet one population is healthy and the other is not.   So what was the difference?  Socioeconomic status within the geographies that the different populations reside.  The same holds true for obesity and hypertension.  In each case, the “hottest” spots for these modifiable risk factors are in lower socioeconomic status areas, while the “coldest” spots are in higher socioeconomic status areas.

What this means is that place shapes disease. Medical care can do very little to affect this reality. That is why Kaiser aggressively invests up to $2B of its $46B budget (yes, roughly the same budget as Ontario’s public health system) into upstream health promotion and social capital. And they will admit that they are barely making a dent – as a health care insurance and delivery system, there is only so much they can do.

Before Ontario goes down a path of attempting major, highly difficult, structural and financial reforms, can we learn from the sobering lesson of Kaiser (who has already been there, done that) and divert as much economic investment as possible – at the Ontario program spend level – into upstream health and promotion? After all, is the goal of our health system to be “a high performing” system? Or is it to improve public health?