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Can Kaiser Permanente’s success be replicated in Canada?


I recently attended a briefing of Ontario health system stakeholders by representatives of the famed Kaiser Permanente Health System, often called America’s leading nonprofit integrated health plan. Kaiser Permanente representatives are regularly invited to Ontario to provide advice (and maybe hope) to the rest of us that health system reforms could produce the same sort of high quality, lower cost (at least by US standards) integrated health system that Kaiser has become known for.

I listened with a mixture of envy and suspicion. Envy at things like a sophisticated IT platform which gives Kaiser providers 24/7 access anywhere in the country to the same comprehensive electronic health record.

And suspicion, wondering about how different Kaiser’s insurance paying and/or employed population of patients is from the Ontario population (they must be better off? better educated? younger?). But according to Kaiser, the demographics of their insured clients are pretty similar to those of the general American population.

Yet as I listened to one of the Kaiser doctors describe the benefits of working within a strong integrated system of care – the emphasis on teamwork, the feedback on practice performance, peer comparisons and accountability for the work they do – it struck me that he did not sound much like a prototypical American doctor (or Canadian one, for that matter). And, in response to a question about that, he admitted that Kaiser’s doctors probably aren’t typical of the average US physician.

Many doctors (American and Canadian) are reluctant, fearful or downright hostile to working in a system that limits doctors’ freedom to practice as they see fit, that regulates things like work hours and vacation time, and that makes them accountable for the quality of the care they provide to their patients. So, Kaiser does the sensible thing: it attracts and hires doctors who are aligned with their vision and way of doing things, and, if (or when) the fit turns out to be poor, a parting of ways between doctor and Kaiser is always an option.

However, in Ontario things are different. If the Ministry of Health, or a LHIN, or a hospital implements a particular policy, they have to work with a diverse population of doctors who will welcome the new agenda with variable degrees of enthusiasm ranging from rapt support to denunciations of socialist medicine, and a medical association (Ontario Medical Association) that will defend individual physician autonomy even while sometimes supporting innovative policy initiatives. And in Ontario, when the fit is poor, a parting of ways between physician and Ministry of Health isn’t an easy option.

Kaiser Permanente has been around for 69 years, longer than even Medicare in Saskatchewan. Today it insures about 9.5 million Americans, in 37 hospitals across 8 states primarily on the west coast and the District of Columbia. Independent rankings rate them as providing excellent quality health care at lower cost. So why is it that after so many years such a successful system covers only about 3% of the US population, while Canada’s Medicare covers close to 100%? Kaiser has carefully expanded over the years, though in a few states it failed and pulled out. Why this happened I don’t know, but the mere fact that Kaiser can pull out of a region where it can’t operate successfully illustrates another difference: our universal health system can’t slowly expand or pull out of geographic regions where care cannot be delivered cost-effectively, it must cover the entire jurisdiction, all the time, regardless of the challenges and costs that entails.

We should look to systems like Kaiser for inspiration, and there is no doubt we have much to learn from integrated health systems in the US and elsewhere. But understanding key differences between our systems and the key enablers will make it easier to identify which lessons hold the most promise for Canada.

Michael Schull is the CEO of the Institute for Clinical Evaluative Sciences and an Emergency Medicine specialist at Sunnybrook Health Sciences Centre. Follow Michael on Twitter @DocSchull

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7 comments

  1. Shawn Whatley MD

    Our love for KP tends to gloss over ‘…key differences between our systems…” as you say. I asked Molly Porter, International Director of KP, what role competition played in KP’s success. She said, “Competition played a huge role in success…we almost went under in 1997-98.”

    Thanks for crafting your well-written post! I feel the same envy for IT and patient-centred service and quality. You might be interested in my very short post (reviewed by Molly Porter) called ‘Canadians Love Kaiser Permanente’: http://shawnwhatley.com/kaiser-permanente/

    Cheers

    Shawn

    http://www.shawnwhatley.com

  2. Michael Pray MD

    For 1 billion $ that was spent by Canada Health Infoway we could have had:
    “a sophisticated IT platform which gives Kaiser providers 24/7 access anywhere in the country to the same comprehensive electronic health record.”

  3. Advice Nurse

    Dreamer. Don’t be taken in by Kaiser officials. The left hand doesn’t know what the right hand is doing at Kaiser, it’s a myth that they are integrated. Kaiser’s IT is highly overrated by Kaiser.

  4. Don Taylor

    Well said, Michael. I would add that our preoccupation with the American system and corresponding neglect of other systems severely limits the quality and usefulness of the perennial Canadian healthcare debate.

  5. Liz Stirling

    The patient- centred care offered by Kaiser to its wide range of patients is remarkable. You line up for a visit like you line up at the bank (at least that was the case 20 years ago- now you likely swipe a card and take a seat) and you see a physician or nurse/nurse pracitioner for triage and then you see the right type of health professional for the problem in a very timely fashion. The incentives work. The approach is based upon knowledge of patterns in acute and chronic disease, risk and care pathways and associated costs all provided by that incredible data base.
    Professionals practice using policies developed by the KP Medical Group itself. They establish their work hours and likely get paid vacation which cant be all bad. The outstanding patient education programs for those pregnant or with chronic diseases impacts utilization of services and optimizes health in a way that Canada has to envy. The only way it works is for patients to become “members” with a single number to dial or website to go to for care and education. In Ontario OHIP only provides insurance coverage which is not care. Do we want the US system- absolutely not. But if we each belonged to a region with a set of hospitals and primary care professionals responsible for our care in a system that might be a good thing. KP works in regions like Northern California where the population density is high and the hospitals which they own are close together. They buy services they cant provide cost effectively. Canada has urban centres where this could work but politicians/bureaucrats, hospitals and physicians would need to give up autonomy for the sake of cost, efficiency and quality of care- the three things KP manages to balance very delicately.

  6. David Walker

    Well stated Michael. I am of the opinion that key to a more effective, efficient, integrated and less costly system is a platform that gathers information and provides intelligence to those in the system. Knowing clearly how one (or the team) should be performing and how one (or the team) is performing provides a most powerful impetus toward quality and cost-effectiveness. %featured%To be aware cognitively of dissonance is to be half way to correcting it.%featured%

  7. Sholom Glouberman

    Everyone who looks at Kaiser sees how good it is. This is a most refreshing look at Kaiser. I think that he most critical lesson that we can learn for it is that it ha remained pretty stable for most of its history. The greatest crisis it faced was the struggle between the managers of the non-profit insurance company that of the practice and the doctor’s group practice over control. That was resolved about 30 years ago. Since then there have been almost no structural changes, and a very careful expansion, mostly to places that want to join.

    In Canada like the rest of the English speaking world, there has one destabilizing restructuring after another. Once the system has a adjusted to one change we quickly devise another, often looking to Kaiser for inspiration.

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