A Frank Chat with Kaiser Permanente

Since we love to gripe about healthcare providers, but rarely get a chance to talk with them frankly, I was excited to recently run into some executives from Kaiser Permanente (KP) at a healthcare blogging event.  Love ‘em or hate ‘em, Kaiser is America’s leading integrated health care organization with a unique nonprofit business model (and also those cool “your-couch-is-a-carb” / Thrive commercials).Dr_mustille_1

They are very interested in Social Media, so it didn’t take too much coercion to get them to agree to a DiabetesMine.com interview with one of their most articulate (and approachable) leaders. Dr. Michael Mustille serves as “Associate Executive Director, External Relations.” A very big PR title. But Dr. Mustille is also an occupational medicine physician with 33 years’ experience and former director of the South San Francisco KP medical center. He now sits on the executive committee of the Permanente Federation, the organization’s medical arm, and is personally involved in quite an array of medical quality initiatives.

Oh, the irony!  Of course I conducted this interview before last week’s allegations of mismanagement and medical misconduct hit the fan.

Anyhoo, here’s what Dr. Mustille had to say about what he believes makes Kaiser effective and how this affects people with diabetes.

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DM) Kaiser has been pioneering in best practices for chronic disease management, even launching the subsidiary KP Healthy Solutions to license out their expertise. So what does KP actually do so well here — for diabetes patients in particular?

MM) Why is Kaiser is such a leader in healthcare? I’d say it’s all about Quality of Care. We’ve exhibited this consistently, and over the past decades two things stand out: our treatment of chronic conditions and our “health & wellness” push for the best possible prevention and screening.

This is actually substantiated using standardized quality performance measures, including those from the NCQA, which monitors quality insurance and certifies health plans/HMOs across the country. They use a standardized data set, and a publicly available rating methodology. (You can look up report cards on any HMO in the US.) Kaiser is at or near the top across the country.

These standards include, for example, a bundle of diabetes-related measures for patients: did you get your A1c tested? Your lipids tested? Your microalbumin measured?  We do sometimes survey patients, but mainly we track the quality of care received from our records, including claims data and chart reviews.

Of course, measuring in these ways isn’t the same as making people healthy in their day-to-day lives. For that, we need a coordinated program of actions/treatments that help get patients where they need to be health-wise – in this case, whether they have pre-diabetes, full diabetes, or complications of diabetes have already set in.

DM) How easy is it for diabetes patients with Kaiser to get their “diabetes care team” – endocrinologist, CDE, nutritionist, podiatrist, etc. – to actually communicate and work together?

MM) One big advantage is shared medical records. At Kaiser, all those people work in the same organization, usually at the same location. In a less coordinated system, your providers are across town and each has his or her own medical records – which are incomplete, because they only show the care you received at that office. KP providers work shoulder-to-shoulder with the same records, measuring real outcomes.

We treat 277,000 patients across the country with diabetes (out of 8.5 million KP members total). We know their A1c, whether have seen the doctor or where in the hospital recently, and whether they’ve filled their diabetes prescriptions. We can tell who they are, where they are, and what level of control they have, so we really know what works in terms of team care.

We’re making a real effort right now to further advance health information technology with a new suite of software applications called KP HealthConnect (Editor’s note: which has also come under scrutiny). Everything important for each member is recorded electronically, including visits, lab results, prescriptions, etc.– no more paper medical records. The information can be shared with any KP provider anywhere.

We’d also like to see interoperability outside of the KP system, so emergency teams and other important providers have some way to retrieve and transmit critical patient data. We’re participating in a national effort to foster the Interoperability of Medical Records.

DM) Isn’t Kaiser helping to establish standards for transfer of information from all different kinds of medical monitoring systems (the Continua Health Alliance)? What are some of the roadblocks or hot buttons there?

MM) Yes, this is a different issue, which is how to make medical devices “talk to each other.” Kaiser is a charter member of the Continua standards committee. The focus is on Home Monitoring Devices – scales, glucose monitoring, blood pressure devices and so on – would connect ideally with each other to some extent and also to a database at your provider’s site.

We’re great at designing systems that sound powerful, but are siloed, meaning they work great only in the scope of their own needs, but don’t contribute to your overall health care. Lots of new devices beg the question: Is this really helpful? Or just confusing, and possibly even dangerous?

These systems are very new, and people tend to lump a number of different monitoring technologies together.  What exactly will their value be, and for whom?  These questions need to be answered by doing some studies.

DM) What about moving to continuous glucose monitoring (CGM) as the standard of diabetes care? Where does Kaiser stand on this issue?

MM) One of the nice things about practicing medicine in KP is that if you have a great idea on how to help people, you can go ahead and try it. A few of our endocrinologists in Southern California identified CGM technology early on and decided to try it. They experimented with patients using Minimed’s model and found it very useful for hypoglycemic unawareness. But most Type 2 diabetics can do very well without such a system.

DM) So are patients encouraged and/or supported to try the latest cutting-edge treatments?

MM) In Kaiser, a CGM device would be covered if the patient cannot achieve good glucose control even after exhausting all the other efforts. That is, we take a step-wise (or evidence-based) approach to using new therapies. We have quidelines for what treatments are appropriate to start with, and what’s the next step and the next step after that.

We don’t consider these things insurance decisions. These are medical decisions at KP.

It really is a matter of the individual and their physician making the decision; if they believe that current therapy isn’t working well, they can decide to move on to the next step.

DM) How is your approach particularly progressive or different from what other healthcare organizations are doing?

MM) We actually have evidence that diabetes patients at KP are doing better than elsewhere. For one thing, we have an innovative way of evaluating actual costs. We’ve created an analytical engine using financial and clinical information to estimate the costs of covering certain populations. For example, we could take all the available information for people who work in a rubber plant in Des Moines, Iowa, and estimate costs for that population.

With this predictive model, we can calculate outcomes 10 years from now if we change the peoples’ treatment, i.e. if we implement a nutrition plan or put them on certain medications, what’s the likely impact on their health complications? This is really significant data, because we can save thousands of dollars and prevent hundreds of heart attacks!

With regard to diabetes care, we can see that there’s generally a return on investment (ROI) of 2 or 3 dollars on every dollar put in. That’s strong financial evidence that proactive diabetes treatment is a huge cost savings for providers in the long run. For employers, it also means less absenteeism, no excess money wasted in redundant treatments, and so forth.

DM) How does all this play out from the patient’s perspective?

MM) We offer our expertise via web-based and phone coaching, in which patients have direct contact with health coaches who help them develop plans for their individual needs. This is not just for chronic conditions, but also for nutrition, exercise, stress reduction, end-of-life care, and much more. This is the service that KP Healthy Solutions helps offer to organizations outside of Kaiser.

We’ve had the biggest impact (cost savings and outcomes) with chronic conditions like diabetes, asthma, coronary artery disease, heart failure, and depression.

Depression is unbelievably relevant. We’ve learned that, for example, a diabetic member generally spends 4x as many days in the hospital than an average member. With depression and diabetes, the member spends 8x as many days in the hospital. So one of the first things we do is screen patients for depression. We also train our care teams on how to identify motivational factors, and we’re making counseling part of the treatment plan.

DM) What about early intervention and pre-diabetes care?

MM) We have guidelines for that, 220 pages of them! Seriously, if a patient has a family history of diabetes or other markers, then we do proactive screening. We also know you can’t apply this kind of care as a cookie cutter approach; it has to be tailored to the individual.

Also, we have a new A-L-L initiative to incorporate cardiovascular risk management into diabetes care. This says BG control is important, but lipid control is also crucial.  Cardiovasulcar complications related to lipid abnormalities are one of the biggest killers of diabetics. A combo of medicines can really help: Aspirin, Lovastatin, Lisinopril.

We’re targeting every diabetic over 55 and those with other complications, such as high blood pressure or coronary artery disease, and putting them on these three meds, which are proven to reduce cardiovascular damage by 20-30%. We see tremendous impact already, because the complications of high BG show up much later, but the cardiovascular problems (heart attack, stroke) typically show up within a couple of years.

Beyond that, we also have an excellent proactive system of patient reminders for your next pap smear, next mammogram, and so on.

DM) Kaiser got pretty beat up recently in the kidney transplant scandal. How is it working to restore patients’ faith in its care?

MM) I must admit that we didn’t handle that well. There’s some irony in the sense that the actual transplant care was good, but we blew it with the administrative part. We failed to get patients transferred onto the new waiting list in order of their existing seniority. So people ended up in limbo on the recipient list.

What are we doing about it? Phasing out the transplant program. We brought the program in-house because we thought we could do better job. But we’re admitting defeat in this area.

What we’re realizing is that we can’t handle this kind of program without a major administrative overhaul. So we’re shutting that program down until we’re sure can we do it right. We’re not giving up on kidney care, but going back to using outside contracted surgeons to conduct the transplants, at UC Davis and UCSF (which is how we did it previously).

DM) Finally, Kaiser’s unique capitation system (members pay a fixed amount per covered “head” per month) makes some people believe they are barred from using Kaiser unless their employer is contracted with the organization. What’s the opportunity for people already diagnosed with diabetes to join Kaiser if they wish?

MM) Most of the people who get into KP do come in as part of an employee group – especially if they have a pre-existing chronic condition, because as part of a group, they don’t need medical screening to join.

If you apply as an individual, you do have to go through screening. And you could be refused or have limitations placed on your coverage, meaning you may have to pay for some treatments out of your own pocket. And to be honest, some people probably do get rejected out of hand. That’s a good reason why most people look to work for a company offering good health insurance benefits.

DM) Dr. Mustille, what’s your message to the diabetes community?

MM) I just think that Kaiser is a very good place for people with diabetes. A coordinated, organized system is the best way to care for a complicated condition like this. So I would say, if you have access to Kaiser, you should take advantage of it.

You won’t hear that from a lot of other health plans – asking potentially expensive members to join… but I would say we do a good job with diabetes, and people should take advantage of it if they can!

Thank you, Dr. M, for giving us the provider perspective; we’ll all be curious to see how Kaiser recovers from the newest scandals and resignations. Ugh.

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11 Responses

  1. Scott K. Johnson
    Scott K. Johnson November 13, 2006 at 7:52 am | | Reply

    Another great interview Amy!

    Thank you!

  2. Scott
    Scott November 13, 2006 at 11:28 am | | Reply

    I think we should all be concerned about privacy invasion with making medical records fully electronic. As someone who has already seen his A1C test results end up in a NYC registry without my consent, or without notice that the city was even seizing my results, it concerns me that companies and government officials alike have such a laissez faire attitude towards protecting patient privacy.

    Also, a recent article from the Washington Post suggests that HIPPAA violations are seldom, if ever, enforced, suggesting that we have to do more to fix what already exists before we engineer new systems designed to make access easier for others to get their hands on our medical data.

  3. Scott
    Scott November 13, 2006 at 11:30 am | | Reply

    Oh, by the way, I was a Kaiser Patient for 6 years when I lived in California, and my perspective was that the care I received was not especially well-organized or comprehensive. I doubt that the situation has changed dramatically since I left California in 1997.

  4. Kevin McMahon
    Kevin McMahon November 13, 2006 at 5:35 pm | | Reply

    Great interview Amy.

    It’s very interesting to read the corporate version of disease management and compare that to my experience over the past several years. Going beyond meters and strips, my team was recruited to develop diabetes programs by several payors who were dissatisfied with traditional diabetes programs like the ones described in your interview.

    These traditional programs have their place but for many people and the payors saddled with the bill, the impersonal nature of top-down patient management is falling short. Issues like privacy and phone calls from strangers walking the patient through a self-care checklist fall short of imparting education, understanding, causality, problem solving skills, reinforcement and encouragement. At least that’s what the participants in our healthcordia diabetes programs tell me.

    If our experience is any indicator, there is a new model of diabetes care which will focus on a patient-centric information technology dashboard for simplified analysis and feedback. What’s cool is the patient really never even sees the dashboard – it’s just working in the background.

    These programs will also include connectivity to a virtual social-support network of the patient’s choosing which relies on technology to connect diabetes teams much like you see in Weight Watchers or exercise partnering programs but without having to go anywhere.

    Another glimpse at the future of diabetes care is simply to understand the impact of credible, decentralized D blogging and figure out how we can distribute that same community effect to the ‘offline’ population at large.

  5. JoAnn
    JoAnn January 7, 2008 at 6:34 pm | | Reply

    My daughter has been type 1 for 15 years and is about to start dialysis. She is with Kaiser & her Endo. is so out of touch with reality it’s ridiculous. Can anyone refer us to a good Kaiser Endo near Woodland Hills, CA…or do “good” & “Kaiser” not go together…many thanks..you guys are GREAT!.

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  8. KAREN
    KAREN November 15, 2011 at 10:07 pm | | Reply

    Regarding Diabetes Type II: I’ve been reading in a lot of literature both in books and on the Internet and have learned that type 2 diabetes is mainly caused as a result of the cells becoming insulin resistant. Insulin resistence can happen a number of ways, but it is most often caused by a diet with a high fat content. I WISHED I HAD KNOWN THIS…. I had always thought that people with Diabetes just ate too much sugar. I have always been careful about this in my diet. If I knew this connection, I would have made changes to my diet a long time ago.

    Currently, I’m making this change (lowering fat) and exercising more (etc.) with big hopes of reversing this condition. I get the feeling Kaiser is of the opinion that once one has been diagnosed as diabetic…that it then becomes a life-long designation. In spite of progress. This is demoralizing, discouraging, and frustrating. In reading books like “Reversing Diabetes” by Dr. Neal Barnard, and others, I’m hoping to reverse the damage that I’ve done to my body and live without meters, medicines. While I appreciate having medical care with Kaiser, I don’t wish to become a patient in need of constant care.

    I like to recommend that instead of stating that there’s a correlation between obesity and diabetes, as well as heart disease, etc. that more of an explanation be provided to the patient to better understand just how unhealthy lifestyle habits can bring about these conditions. Also, that no one should feel helpless, or that they are stuck in a quicksand situation…but that with efforts made to change lifestyles and habits, that they can regain their health, becoming free of diabetes, heart desease, etc.

    I need a recommendation of a doctor in the Los Angeles area who will work with me on this issue. I need someone who is a little more up-to-date on more holistic/homeopathic/healthy ways of healing.

    Years ago, I suffered from acid reflex disease for about 12 plus years. The doctor gave me a prescription for tagamet (over the counter) and told me that the condition would get progressively worse, and that I would need more medication. This doctor was right; it got worse and I double, tripled plus my medication. Then one day, one of the monks of my church gave me a 20 minute lecture on the benefits of eating organic vegetables. I had previously thought those who did this were a bit crazy; but he made a believer out of me. I didn’t increase my vegetable intake, I just switched to organics. Within four months, I noticed that it appeared that I didin’t need my usual nightly anacids. I began to cut back, until now for approx. last two years I rarely need to take them. I eat citrus, a lot of spices, including hot ones, and no problem with acid reflux. I reversed my acid reflux disease.

    This gives me hope that I can reverse type ii diabetes. A condition brought on by lack of exercise and a high fat content diet.

  9. ChristinaC
    ChristinaC July 10, 2012 at 6:05 pm | | Reply

    If anyone has any pointers for getting Kaiser to cover CGM, please reply. My understanding of the current policy is to only offer it to patients who have unrecognized lows. So what do us who are in good control do. It would be such a beneficial piece of technology for those of us who are athletic and could use the info to head off low prior to hitting the 50s or as we increase our training for various events, or have just an off day where we want better monitoring for a few days until we can get back on track. I feel penalized because I’m too healthy of a diabetic!! I don’t wind up in the ER (ever) for diabetes issues. But I will be living with Type 1 diabetes for a long time (23 years down and 30+ to go!) I have already filed a grievance with Kaiser, but it has been denied. I know non-Kaiser people whose insurance DOES cover CGM. Any pointers?

  10. KAREN
    KAREN July 6, 2013 at 9:33 am | | Reply

    Dear Amy—-this is more updated:

    It is very important to expand your knowledge outside the boundaries of conventional medical profession. It’s a very big business and I’ve heard often that there’s no money in curing/eliminating a chronic condition, but lots of money in ONLY Managing it and allowing it to slowly progress. I’ve read over and over that Big Pharma has a lot of influence and power or what doctors are required to do.

    In less than one year my AIC went from 16.5 to 6.2, initially with medication (metformin and lisinprl) and later without medications. I’ve been without diabetic medications for over a 1.5 years. Below are some sources of information that helped me to do this:

    Dr. Neal Barnard http://www.amazon.ca/Neal-Barnards-Program-Reversing Diabetes/dp/1594868107/ref=sr_1_1?s=books&ie=UTF8&qid=1322611282&sr=1-1

    Dr. Gabriel Cousens http://www.amazon.ca/There-Cure-Diabetes-21-Day- Program – I saw the video.

    Death to Diabetes by DeWayne McCulley…he had a BG of 1332 when diagnosed…he had been taking Lipitor; along with an unhealthy diet of a lot junk food and little to no exercise. After diagnose he went from taking 4 shots of insulin to no medications and an AIC of 4.5 in approxi. six months. Among other healthy habits, he found that dark greens are a great healer for the body. It’s been approx. ten years and he’s still around 4.7. I recently spoke to him; he’s easy to get in touch with.

    My plan was to perform more liver and glabladder flushes in an attempt to provide further healings. I have already performed one flush…my average fasting BG has decreased from being in the 90′s to in the 80′s. IN ADDITION: My allergies decreased significantly, my knee pain decreased so walking up and dwownstairs not painful, and FREQUENT HOT FLASHES turned into once in a while warm flashes, etc…

    I’m drinking organic veggie/fruit smoothies and bowlfuls of whole grains each day, and fasting one day a week. I’m still taking herbs to heal the pancreas…per UCLA and UC of California studies Indian studies, etc. Another good book to read:

    “The Amazing Liver & Gallbladder Flush – A Powerful Do-It-Yourself Tool To Optimize Your Health and Wellbeing” by Andreas Moritz

    Best of luck and health to you.

    P.S. Review Dr. Mercola’s website…8 minute video “Death by Medicine” – Mercola.com. So many of our senior citizens started by taking one medication and are now taking upwards of 20 medications a day. I don’t want this future…I don’t think any of us do.

  11. KAREN
    KAREN July 12, 2013 at 9:50 am | | Reply

    Dear Amy, or anyone else put there…

    I’m recommending a few more books to read:

    The Blood Sugar Solution by Dr. Mark Hyman;

    The 30-Day Diabetes Cure by Dr. Stephan Ripich, ND, CNP, and Jim Healthy;

    Drug Muggers – Which Medications are Robbing Your Body of Essential Nutrients – and Natue ways to Restore Them by Suzy Cohen, RPh.

    Best of luck and health to all.

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