“HMO”: A “Good” Three-lettered Word
Note: This article from Dr. Bernstein begins a series of occasional articles from our San Diego County medical directors.
You’re on the exam table, wearing a flimsy gown, and worrying what the doctor may find. The paper crunches under you, and a sudden chill needles your neck. You’re not sure if it’s the room temperature or your nerves. In his calm, trusting manner, the doctor reassures you that you passed your physical and everything is fine, but then, instead of rushing off to his next patient, he shares your test results with you on a computer in the exam room, even brings up an image of your last MRI, before counseling you on blood-pressure control and the use of aspirin and cholesterol-lowering drugs to reduce your risk of heart attack. He explains that people your age who follow his advice have a 30 percent decrease in death rate from heart disease. This patient and doctor were part of Kaiser Permanente, the nation’s largest non-profit health maintenance organization.
Prepaid medical care — now known as managed care or simply as an HMO — has been around for 70 years. Born out of the challenge of the Great Depression and World War II when patients had the choice of either paying expensive doctors’ fees or going to a charity hospital, Dr. Sidney Garfield, a young surgeon, and industrialist Henry Kaiser created Kaiser Permanente, the first and now the largest nonprofit HMO.
HMOs are prepaid a single premium and are motivated to keep you healthy. They do everything they can to encourage you to come in for mammograms, diabetes testing, colonoscopies, vaccinations, weight-loss programs, no-smoking classes — the list goes on. The better they take care of you, the less sickness you have, the lower the costs are to them. Kaiser Permanente currently leads the nation in colonoscopy screening and mammograms in women over 65, and will soon lead in blood-pressure screening.
Learnings from Kaiser Permanente highlight the effect of lifestyle and clinical risk on medical costs that can be attributed to the following 15 key risk factors: excessive alcohol consumption; high blood pressure; high BMI; high total cholesterol; low HDL cholesterol; excessive work absences; low job satisfaction; low life satisfaction; fair or poor perception of health; low level of physical activity; lack of consistency wearing seat belt; smoking; high stress; use of drugs for relaxation; and existing medical problem. Exercise is also medicine. If we had a pill that conferred all the proven health benefits of exercise, physicians would prescribe it to every patient, and our healthcare system would find a way to make sure every patient had access to this wonder drug.
Not all HMOs are created equally. There are two models of HMO care: for-profit and nonprofit. A nonprofit HMO health plan, like Kaiser Permanente, reinvests all revenues back into quality patient care. Its incentive is to keep you healthy and prevent illnesses such as heart disease and cancer because healthier people require less costly care. Efforts to contain costs are done solely to provide quality healthcare at a price you can afford. It’s no surprise that a Consumer Reports study of 20,000 people showed that patient satisfaction rates were much higher in nonprofit HMOs.
Our experience at Kaiser Permanente has taught us several lessons. We have our electronic medical record, which provides a powerful tool for outpatient and inpatient care. We also possess a prevention culture ingrained in our genetic code based in the roots of our organization. As well, we developed a vision of wellness through our THRIVE advertising campaign that was visible to our members and potential members. Our strategy was based on delivering affordable and demonstrable, high-quality healthcare that was both easy to access and provided with a personal touch. We both demonstrated and were recognized that we could be the prevention leader.
Most physicians want nothing other than to keep you healthy. But no matter how dedicated we are to the Hippocratic Oath, no matter how much we want to be Good Samaritans, in the end, to keep our practices going, doctors have to bill. In the current state, healthcare costs continue to skyrocket, traditional health management approaches are insufficient, rising costs create the need to do “more with less,” and demands on employees increase. As a result, employee health and productivity is a growing concern for employers. All of my decisions on care are based on what’s best for the patient. The patient and I are on the same team. That’s why I’ve looked forward to going to work every day for the last 25 years.
Okay, you can put your clothes back on now. H … M … O … let the three letters come off your tongue more upbeat. As my son would say: “Dad, it’s a no-brainer.” We should pay doctors for keeping us healthy. To put it simply, American medicine needs to change from a “sick plan” to a “health plan.”
At Kaiser Permanente, we believe that the conversation about health needs to change from health as the absence of disease to health as vitality and energy, from only caring for the sick to enabling healthy people to stay healthy, from the cost of healthcare to the total value of health, from individual participation to population engagement, and from behavior change to a culture of health.
As the numbers of the uninsured (45 million Americans, one in five Californians) spiral out of control, competing nonprofit HMO models may be the best solution to our nation’s health crisis. Trust me, I’m a doctor.