About
Kaiser
of
California
Health care organizations, including Kaiser Permanente, have become a main feature of many political campaigns and have received a great deal of media scrutiny.
As a service to our members and health care consumers in general, we offer these answers to frequently asked questions about medical care. We hope that this provides the information you need about important health care issues, and how Kaiser Permanente provides care.
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Who makes medical decisions at Kaiser Permanente?
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At Kaiser Permanente, medical decisions are made by physicians and their patients working together. The doctor-patient relationship is the foundation of our care.
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Does Kaiser Permanente use "gag clauses" that prevent physicians from discussing health care options with their patients?
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Kaiser Permanente strongly opposes "gag clauses" that prevent physicians from discussing treatments not covered by the Plan, possible referrals outside the Plan, or how physicians are compensated. Our physicians are encouraged to tell patients about all the treatment options that are available, no matter what the Plan covers.
Keeping information from patients to benefit a health plan's bottom line is ethically wrong and forces patients to second-guess their practitioners. At Kaiser Permanente, our physicians use their clinical expertise to let patients know about the full range of treatment options, and to help patients take an active role in health care decisions.
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Physician compensation
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How are Kaiser Permanente physicians compensated?
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Our doctors are compensated as a result of a two-step process: (1) Health Plan pays the Medical Group; and (2) the Medical Group pays the doctors. A summary of these steps is provided below.
Health Plan pays the Medical Group
Each year at Kaiser Permanente, the Health Plan and the Medical Group in each region negotiate and agree on the total amount of money that is estimated will enable our physicians and other clinicians to provide the amount of professional medical care that our members are expected to need in the upcoming year. This estimate is based on the previous year's performance (and the years prior to that), and also includes administrative and other expenses associated with operating the Medical Group.
That total is then divided by 12 months, and then divided by the number of expected members in the coming year. That calculation results in an amount of money (the "capitation") that the Health Plan pays to the Medical Group on a monthly basis for each member.
In addition, the Health Plan reimburses the Medical Group for its actual cost for certain medical and other expenses that may be difficult to forecast, such as transplants and contingent expenditures. The total is called the "basic contractual payment."
In the event that the total of all payments, as adjusted throughout the year, is insufficient to provide the needed care, Kaiser Permanente dips into its reserves for shortfalls. Then, during the following year, dues may be raised and reserves replenished. If the basic contractual payments, including the capitated payments, are greater than the actual cost of the necessary medical care, then the Medical Group, as a whole, is permitted to share in some of the surplus.
The remainder is retained by the Health Plans to fund reserves, build hospitals and/or other medical facilities, keep dues lower than they otherwise would be, and the like. Some of the regional Health Plans also reward a Permanente Medical Group for improvements in member satisfaction and/or improvements in preventive medicine or other quality standards.
Medical Group pays the doctor
After the Health Plan pays the Medical Group, the Medical Group uses that money to pay its doctors and other personnel, and to meet its other expenses.
The primary compensation method used by all of the Medical Groups is salary. Salary generally varies with medical specialty and tenure. Smaller amounts of additional compensation may be paid for, among other things:
- board certification
- achievement of specified clinical quality measures
- achievement of member satisfaction levels
- productivity
- continuing medical education
- managerial work
- work performed in excess of normal work time, etc.
In addition, in some Medical Groups, the excess money that the Medical Group retains, if the basic contractual payments exceed the actual cost of care on a regional basis, also may be used to pay additional compensation to doctors and other personnel.
As of 2002, approximately 95 percent of physician compensation was paid in salary.
This is a summary of the arrangements between each of the regional Health Plans and Medical Groups and each of the Medical Groups and their respective doctors. These arrangements vary by region.
Some people believe that capitation payments carry an incentive for preventive medicine to keep patients healthy. Other people believe that capitation payments provide physicians an incentive to withhold treatment.
We believe that our compensation process does not create an incentive for our physicians to make patient care decisions based upon factors other than the medical needs of the patient because Kaiser Permanente's form of capitation is based upon:
- collective performance, rather than the individual performance of a physician, and
- Permanente physicians are compensated primarily by salary.
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I've heard that HMO administrators pressure physicians to discharge their patients from hospitals, including women who have undergone mastectomies. What does Kaiser Permanente do?
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At Kaiser Permanente, clinical decisions are made by physicians working with their patients. The decision of how long a mastectomy patient stays in the hospital, or whether a hospital stay is recommended, is based on what is medically and psychologically appropriate for each individual patient.
Outpatient mastectomies (in which the patient goes home the same day of surgery) are becoming more common, and many women choose to recover in the comfort of their homes, with appropriate support, instead of in the hospital.
Kaiser Permanente does not require mastectomies to be performed on an outpatient basis, and there are no restrictions on coverage for overnight hospitalization, if this is what the physician recommends. If, after surgery, a patient's medical or emotional state indicates the need for an overnight stay, this care is provided. Our highest priorities are the successful outcomes of surgeries, and the emotional well-being of our patients.
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I've heard that HMO administrators pressure physicians to discharge their patients from hospitals, including new mothers and their babies. What does Kaiser Permanente do?
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At Kaiser Permanente, clinical decisions are made by physicians working with their patients. The decision of how long a mother and her newborn baby stay in the hospital is made by the physician in consultation with the mother, based on what is medically appropriate for the mother and child. If there is a medical reason to extend the stay, our physicians decide with patients when discharge is appropriate.
Each year, Kaiser Permanente is responsible for nearly 80,000 births. We have the experience and the data to demonstrate that having a baby at our hospitals and medical centers is a safe and satisfying event. Kaiser Permanente focuses on promoting good health and regular care throughout a woman's pregnancy—including quality prenatal and postnatal care.
Many mothers and newborns can leave the hospital within 24 hours from birth. Many women prefer the comfort of home, away from the noise and disruptions of the hospital, for recovery.
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Recently I've heard a great deal about HMO drug formularies that restrict patients' access to necessary pharmaceuticals. Does Kaiser Permanente use a formulary, and who decides which drugs are included?
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Kaiser Permanente has developed prescription drug formularies—lists of drugs that have been approved by review boards of Kaiser Permanente physicians and pharmacists--to ensure that appropriate medications are available for our members, while also providing these drugs cost effectively. Kaiser Permanente's formularies are doctor-driven and quality-based.
As an integrated delivery system, Kaiser Permanente seeks input from the entire range of health care specialties in developing our formularies. In doing so, we evaluate each medication for:
- safety
- effectiveness
- patient convenience
- patient compliance
- effect on the number of calls and visits to physicians, emergency rooms, and hospitals
- quality of care
- number of side effects
- as a last consideration, cost
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I've heard that the quality of care provided by HMOs is inferior to that provided under traditional, fee-for-service coverage. How does Kaiser Permanente ensure quality?
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At Kaiser Permanente, one of our top priorities is to continually improve the quality of health care we provide. By coordinating patient care and working closely with their fellow physicians, the Permanente Medical Group physicians lead the way in improving clinical practice, conducting medical research, and improving overall health care quality for our members and our communities.
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I've heard that HMOs deny patients access to care in order to please Wall Street investors and ensure their profitability. Is this true for Kaiser Permanente?
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Because we are a nonprofit health plan, Kaiser Permanente is not publicly traded. We do not have shareholders and, therefore, can invest our resources in providing affordable, quality health care for our members and the communities we serve.
Learn more about who we are and the structure of Kaiser Permanente.
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I've heard that HMOs don't provide coverage for the poor and the uninsured, and don't participate in medical research. How does Kaiser Permanente address these important social goals?
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We contribute to a wide range of community programs and activities across the nation. These efforts include:
- providing health coverage through our dues subsidy programs to those who otherwise could not afford it
- providing subsidies to help individuals and small employer groups afford health coverage
- contributing to medical knowledge and to the improvement of clinical care nationally through our clinical and health services research projects
- offering education and training programs for physicians, nurses, and other health professionals
- partnering with local governments to meet community needs
- providing grants, equipment, expertise, and volunteer hours to community organizations
Kaiser Permanente has established a national program for uninsured children. We devote a minimum of $30 million annually to subsidize health care coverage for uninsured and underinsured children, with a goal of helping 70,000 children each year.
Advancing medical knowledge through clinical and health services research is a key part of helping to improve the health of communities. Our community investments support research for important medical and social needs such as:
- preventing violence
- preventing infectious disease
- improving health care for adolescents
- improving health care for underserved populations
For nearly 50 years, Kaiser Permanente researchers have turned modest grants into major discoveries that have served our communities, influenced national policy, and affected medical practices throughout the nation and the world.
Learn more about our community involvement.
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I've heard about an HMO consumer bill of rights and other HMO reform legislation. What is Kaiser Permanente doing to address consumer concerns?
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Kaiser Permanente has joined the American Association of Retired People, Families USA, HIP Health Insurance Plan, and Group Health Cooperative of Puget Sound in proposing consumer protection principles.
Kaiser Permanente, with the American College of Emergency Physicians, also supports national legislation that would assure appropriate access to emergency medical services. We believe that a single national standard should be developed so that the costs of conflicting or duplicate federal and state enforcement measures are reduced.
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A Preferred Provider
Organization (PPO) provides a list
of contracted "preferred" providers
from which to choose. You receive
the highest monetary benefit when
you limit your medical care services
to those providers on the list. If
you go to a doctor or hospital that
is not on the preferred provider
list referred to as going
"out-of-network", then the plan
covers a smaller percentage of your
medical care expenses or may cover
none of your medical care expenses
based on the contract wording of the
plan. Always check with your PPO or
consult your list of preferred
providers before you seek medical
care services to make certain your
physician or hospital is a
contracting provider (part of the
network). Make sure that your doctor
refers you to medical care providers
within your PPO network, if
applicable.
PPOs in
California can be regulated by
either the CDI or the Department of
Managed Medical Care (DMHC) depending
on whether the underwriting company
(the company backing the policy) is
a licensed insurance company or a
managed care company. The DMHC has
sole jurisdiction over
Blue
Cross/Blue Shield PPO medical plans.
If you are confused about whom to
call regarding a PPO problem or
concern, then consult your plan
documents for regulatory
information. If there is still some
question, then you can reach the CDI
or the DMHC for assistance at the
contact information given in the "Resources"
section of this brochure.
Important Points to Remember
About Preferred Provider
Organizations:
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You receive the highest monetary
benefit when staying within the
PPO network.
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You may have the option to go
outside the PPO network at a
higher monetary cost to you.
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You should consider checking if
your doctor or any specialist
referred to you is part of the
PPO network before utilizing
covered services.
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You can seek the assistance of
the DMHC on all Blue Cross/Blue
Shield PPO medical plans.
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You can contact either the CDI
or the DMHC for clarification
regarding PPO issues.
Membership in a Health Maintenance
Organization (HMO) requires plan
members to obtain their medical care
services from doctors and hospitals
affiliated with the HMO. It is
common practice in HMOs for the plan
member to choose a primary care
physician who treats and directs
medical care decisions and who
coordinates referrals to specialties
within the HMO network. The doctors
and hospital personnel may be
employees of the HMO or contracted
providers. Since HMOs operate in
restricted geographic regions, this
may limit coverage for plan members
if medical treatment is obtained
outside the HMO network or coverage
area.
California HMOs are required
to cover
medically necessary
emergency services even when outside
of their coverage area. The intent
of managed care products is to
create less costly delivery of
medical care services while
maintaining quality medical care by
specifying provider choice. HMOs
offer access to a comprehensive
package of covered medical care
services in return for a prepaid
monthly amount (premium). Most HMOs
charge a small copayment depending
upon the type of service provided.
All
HMOs in California are regulated
by the Department of Managed Medical
Care (DMHC). If you have a complaint
with an HMO, contact the member
services department of your HMO.
HMOs are required to have an
internal complaint/grievance process
in place. If you file a grievance
and it has not been resolved within
30 days or there is some question as
to the HMOs decision, then you may
contact the DMHC for assistance.
Please see contact information
listed for the DMHC in the
"Resources" section of this
brochure.
Important Points to
Remember About Health Maintenance
Organizations:
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You must obtain medical care
services from HMO providers,
except in certain emergency
situations.
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Your choice of primary care
physician is important because
he/she directs your care. Also,
your primary care physician
often coordinates referrals to
specialties within the HMO.
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Your options may be limited by
the geographic restrictions of
the HMO network.
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You may be charged a small
copayment each time you utilize
an HMO covered service.
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You can seek assistance from the
DMHC on all HMO and managed care
questions.
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