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How one physician’s revolutionary vision paved the way from a 12-bed hospital in the Mojave Desert at the height of the Great Depression to what is today the nation’s largest, most successful THE STORY OF nonpro t health care organization — Kaiser Permanente. Like the architect he always wanted to be, physician Sidney R. Gar eld spent most of his life designing and building a model of a new kind of health care. Built on the foundations of group practice (as opposed to solo practice), prepayment (as opposed to fee-for-service), and prevention and health promotion (as opposed to sick care only), it was in many ways the opposite, mirror-image of the way health care was nanced and delivered in the rest of America. In partnership with Henry J. Kaiser, one of the great industrialists of the early 20th century,

Gar eld stood rm against waves of early opposition from mainstream medicine and went on DR. SIDNEY R. GA R to build one of the most acclaimed and successful health care organizations in America. This book tells the story of Dr. Sidney Gar eld’s long and eventful career in turning his desert dream into a thriving and enduring reality that continues to oer a practical model for the future of American health care.

C M Words from Permanente Medical Leaders Y

CM Thank you for the advance copy of your new Dr. Gar eld was a remarkable man and this

MY book on Dr. Gar eld. I could not stop reading book does an excellent job of chronicling his FIELD CY it until I had nished it all. Congratulations on contributions. I am optimistic that as a result of

CMY a great book that will help new readers better his visionary leadership, Kaiser Permanente is

K understand and appreciate Gar eld's genius about to become the model for health care in and persistence. this nation. — Morris F. Collen, M.D., Emeritus Director, — Robert Pearl M.D., Executive Director and CEO, Division of Research, The Permanente Medical Group, The Permanente Medical Group, and President and CEO, Gar eld colleague and friend The Mid-Atlantic Permanente Medical Group DEBLEY

Cover image © St. John Moran Cover design by Lynette Leisure US $19.95

TOM DEBLEY

The Permanente Press IN COLLABORATION WITH Oakland, California • Portland, Oregon JON STEWART The story The of

TheDr. VisionarySidney R.Who Gar Turnedfield Sick Care into Health Care

TT O O M M D D E E B B L L EY Y E D INI T ECOLLABORATION D B Y J O N S T EWITH W A R T JON STEWART

The Permanente Press Oakland, California • Portland, Oregon About the Authors: Tom Debley is Director of Heritage Resources for Kaiser Permanente. Trained originally as a journalist, he had a career as an award-winning reporter for many years before moving into public affairs and history work. He has worked on significant historical research and related communication projects for the University of California in addition to Kaiser Permanente.

Jon Stewart is Director of Communications for Government Relations and Health Policy at Kaiser Permanente and an editor of The Permanente Journal. Following a long career in daily journalism, he joined Kaiser Permanente as the first communications director for The Permanente Federation, the umbrella organization for all the Permanente Medical Groups, on whose behalf he has championed the history and the promise of Permanente Medicine.

Cover: The painting of Dr. Sidney Garfield by St. John Moran hangs in the Board Room of The Permanente Medical Group in Oakland, California.

© 2009 by The Permanente Press

Published 2009 by The Permanente Press Oakland, California • Portland, Oregon

The Permanente Press is owned by The Permanente Federation, LLC Oakland, California

THE STORY OF DR. SIDNEY R. GARFIELD THE VISIONARY WHO TURNED SICK CARE INTO HEALTH CARE

13 12 11 10 09 1 2 3 4 5

ISBN: 978-0-9770463-2-4 Library of Congress Control Number: 2008944214

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, without permission in writing from the publisher. Permissions may be sought directly from The Permanente Press Publishing Office, 500 NE Multnomah Street, Portland, Oregon, 97232 USA; phone 503-813-4387, fax 503-813-2348.

Book design by Lynette Leisure Printed in the United States of America 

Dedicated to the tens of thousands of Permanente physicians who have followed in the wake of Sidney R. Garfield, M.D.

v Table of Contents

Foreword: The Lasting Legacy of Sidney R. Garfield, M.D...... ix Preface ...... xix

Prologue: The Desert Doctor ...... 1 Chapter 1: Out of the Immigrant Forge ...... 6 Chapter 2: The Great Depression and “Social Medicine” ...... 10 Chapter 3: Revolution in the Economics of Medicine ...... 17 Chapter 4: A Fateful House Call ...... 22 Chapter 5: The Final Dress Rehearsal ...... 28 Chapter 6: FDR to Garfield: “You’re Not in the Army Now!” ...... 34 Chapter 7: Postwar Challenges: Rebuilding Against a Tide of Opposition ...... 50 Chapter 8: Attack from the Rear Guard ...... 57 Chapter 9: Prosperity in the Postwar Boom ...... 67 Chapter 10: Toward Tahoe: Crises and Crossroads ...... 75 Chapter 11: After Tahoe: Pursuing New Frontiers ...... 85 Chapter 12: The Best Is Yet to Come ...... 93

Appendix 1: Remarks to the AMA on Promoting Prepaid Group Practice ...... 109 Appendix 2: A Report on Permanente’s First 10 Years ...... 112 Appendix 3: From An Address to the Permanente Monterey Management Conference ...... 115 Appendix 4: From An Address to the Board of Directors of The Permanente Medical Group . . . 117 Appendix 5: The Delivery of Medical Care ...... 120

Bibliography ...... 133 Selected Works: Authored or Coauthored by Sidney R. Garfield, M.D...... 135 Index ...... 139 A Timeline of the Life of Sidney R. Garfield, M.D...... 148

vii Foreword The Lasting Legacy of Sidney R. Garfield, M.D.

By Jay Crosson, M.D.

It’s about time. For too long, Sidney Garfield, M.D., has stood in the gi- ant shadow cast by his more celebrated partner and friend, Henry J. Kaiser, the great entrepreneur and industrialist. Mr. Kaiser’s name and fame live on, mainly in association with the only nonprofit organization ever incorporated by the builder of more than 100 for-profit companies — Kaiser Permanente. But the physician whose extraordinary vision and daring innovations in health care delivery gave birth to that same organization remains largely unrecognized beyond the select circle of medical historians and the heritage-minded physi- cians and staff of Kaiser Permanente. One needn’t minimize the vital role of Mr. Kaiser in Kaiser Permanente’s story to assert the seminal role played by Dr. Garfield. They were genuine partners, each bringing to the enterprise critical elements lacking in the other: money and organizational genius from Mr. Kaiser; a visionary mind and an unrelenting drive for innovation and quality improvement from Dr. Garfield; and from both a genuine belief in and commitment to human dignity and progress. The recent centennial of Dr. Garfield’s birth in 1906 provides a timely occasion not only to recall and celebrate his role in creating and evolving the unique model

ix THE STORY OF DR. SIDNEY R. GARFIELD

of health care delivery that would become Kaiser Permanente, but to examine as well some of his key insights and innovations with regard to the current and future state of American health care. Anyone who has examined Dr. Garfield’s long career will appreciate the difficulty of assessing the historical and/or current relevance of his ideas and innovations. As his diminishing number of surviving colleagues will attest, he was a fount of ideas — virtual intellectual fireworks — admittedly igniting a few duds among the brilliant rockets. The ideas ranged across the entire spectrum of health care, from delivery models to financing to hospital design. In the end, it may fairly be said that he achieved his childhood dream of becoming an engineer (he is said to have broken down and cried when his parents insisted he attend medical school) by engineering our unique model of health care. But among all his many lasting contributions, which ones constitute the essential core of his life’s work? And what relevance do they have for today and tomorrow? I believe Dr. Garfield’s lasting reputation will rest on four big ideas that, in- dividually and in combination, powered fundamental transformations in health care. They are: • the change from fee-for-service to prepayment; • the promotion of multispecialty group practice in combination with prepayment; • the emphasis on prevention and early detection to accomplish what he termed “the new economy of medicine,” in which providers would be rewarded for keeping people healthy; and, • finally — and most presciently — the centrality of information technology in the future of health care. Significantly, each one of these 20th century innovations, three of which are deeply embedded in Kaiser Permanente’s own genetic code, is at or near a criti- cal crossroads in this first decade of the 21st century, as the nation considers its options for redesigning the American health care system. Let us briefly examine each in turn. x The Lasting Legacy of Sidney R. Garfield, M.D.

Prepayment In his work, in the 1930s, at his little fee-for-service Contractors General Hospital in the Mojave Desert caring for aqueduct construction workers, Dr. Garfield was saved from the looming threat of bankruptcy by the discovery of prepayment to the delivery system for comprehensive services. The idea was borrowed from the Ross-Loos Clinic in Los Angeles County and was rooted in the late 19th century traditions of “industrial medicine.” Collecting a dime a day from approximately 5,000 aqueduct workers, Dr. Garfield’s desert office and small hospital prospered under prepayment, and his eyes were opened to the transformation of care made possible when wellness rather than sickness became a revenue source. Prepayment, he said, “is the old principle of the well paying for the sick; the houses that don’t burn down paying for those that do.”1 But even more important, he noted, prepayment “brings the patient to the doctor earlier in his illness and more often, which is one of the most important effects … because it permits the practice of true preventive medicine. Any plan that sets a barrier between the patient and the doctor by eliminating the first two or three visits, by covering the patient only for hospital or surgical care, or by limiting this coverage in other ways, in our opinion defeats its purpose and is not good.”1 Employer-based prepayment led Dr. Garfield inevitably to a focus on preven- tion and what would come to be known as health maintenance and wellness. It solved for him the critical question of the economics of medicine: “how to keep the people of this country well and healthy and, at the same time, preserve the medical and hospital organization which must do that job, but under our present (fee-for-service) system derives its income out of sickness.”1 Prepayment for comprehensive services has served as one of the critical strands of Kaiser Permanente’s DNA since the very beginning of the organization when Dr. Garfield first partnered with Mr. Kaiser to provide employee health services at Grand Coulee Dam and later in the World War II shipyards. Yet 60 years later, in an era of industry-wide cost-shifting and a proliferation of high-deductible plans,

xi THE STORY OF DR. SIDNEY R. GARFIELD

we are confronting a question that Dr. Garfield might have found unthinkable: Would Kaiser Permanente still be Kaiser Permanente without prepayment? The principle of prepayment for comprehensive services is challenged today, primarily because the growing cost of health coverage has pushed employers to fa- vor insurance plans with high deductibles and to move toward self insurance. Each of these is to some degree in conflict with the concept of prepaid, comprehensive benefits that have long been a defining feature of Kaiser Permanente. High deductible plans create financial disincentives for patients to seek preventive services and can lead patients to forego coordinated office-based care for chronic dis- eases such as hypertension and diabetes. What is the right balance between unfettered, out-of-pocket personal liability for health care and open-ended social insurance? Kaiser Permanente, as well as those seeking to design the best model for national universal health coverage are struggling with this question at this time. In the long run, there is good reason to believe Kaiser Permanente can and will adapt to the market and to health care reform by developing more intelligent and clinically sound cost-sharing benefit designs without creating significant barriers to needed care. Such work is currently under way under the term “value-based benefit design.”

Multispecialty Group Practice With the financial security provided by prepayment, Dr. Garfield was able to realize his second great contribution to what would become Permanente Medicine — multispecialty group practice. Here again the idea was not unique to Dr. Garfield, but borrowed from other pioneers, such as the Mayo brothers in Minnesota and, especially, Dr. Garfield’s own experience with a form of group practice at Los Angeles County General Hospital. There he had served as a chief resident with other first generation Permanente physicians, including Wallace Neighbor, M.D., (first Medical Director of what would become Northwest Permanente) and Raymond Kay, M.D., (founding Medical Director of the Southern California Permanente Medical Group). “We grew up at the county hospital,” was how Dr. Garfield put it.1 xii The Lasting Legacy of Sidney R. Garfield, M.D.

“It has always seemed a paradox,” said Dr. Garfield in later life, “that in universities, which teach us medicine, we learn medicine under the highest type of group practice, but when we go out into practice, we revert to the old type of individual private practice.”1 Dr. Garfield’s great contribution to the evolution of group practice was to layer onto it the additional power of two other elements: prepayment and integration of the medical group with what he termed “adequate facilities” — “bringing the doc- tors’ offices, laboratory, X-ray, and hospital … all together under one roof.”1 Group practice alone could be a powerful engine for continuous learning and coordination of care; integrating it with the full range of medical facilities served to align the oth- erwise conflicting interests of doctors and hospitals; and then layering on prepayment removed financial barriers to care while opening the door to prevention and health maintenance. With all these elements in synergistic combination — first achieved at Dr. Garfield’s Mason City Hospital at Grand Coulee Dam, where Mr. Kaiser first saw and embraced Dr. Garfield’s vision — the young surgeon, still in his mid-30s, had engineered the miracle of Permanente Medicine. Over the past 60 years, the Permanente Medical Groups, which evolved out of the old Garfield and Associates, have been more successful than any group in the country at exploiting and enriching the possibilities of multispecialty group practice — largely because of the grafting on of prepayment and integrated facilities, as well as our sustaining partnership with Kaiser Foundation Health Plan and a tradition of great physician leadership and professionalism. This unique model has set the standards for both efficiency and clinical quality in most of the communities in which we operate, and it continues to be touted by some of the smartest minds in the country (and not all within Permanente) as the best solution to the multiple crises besetting American health care. And yet, 74 years after the National Committee on the Costs of Medical Care advocated group practice as “essential” to “meet the modern demands of medical science and technology,”2 group practices still occasionally have to defend this style of practice against the tradition of solo and small group practice. What’s more, it is facing

xiii THE STORY OF DR. SIDNEY R. GARFIELD

significant challenges from the concept of so-called “high-performance networks,” an insurance-company driven promise of “groups without walls” — and, in most cases, without clinical coordination or any form of economic integration. Given the disaggregated nature of the delivery system in most communities today, insurers have been able to promote the idea that they can achieve all the advantages of an actual group practice by profiling individual doctors and hospitals, selecting the most efficient providers, and then lumping them all together into a pseudo-systemic “high-performing network” with an external stand-alone disease management com- ponent. In a world that still clings tenaciously to Marcus Welby, M.D., it looks to some like a reasonable alternative to genuine group practice. However, performance measurement systems such as the HEDIS measurements of the National Committee for Quality Assurance (NCQA), and academic studies such as that by Gillies, et. al.,3 show clearly that group practice-based care produces better results for patients.

Prevention As I have noted, preventive health care and health promotion became an early principle of Permanente Medicine as a direct result of prepayment, which put a premium on keeping workers (and, later, whole communities) healthy. Recalling his early experience with prepayment in the Mojave Desert, Dr. Garfield noted that the “financial result (of prepayment) was impressive, but another result impressed us very much — a resulting change in our attitude. Prior to (prepayment), we were anxious to have injured workers come into the hospital, since it meant remunera- tion … Under the new arrangement, we had the same amount of income whether the workers were injured or not. Obviously, we were better off if they remained unhurt.”1 And thus began Dr. Garfield’s long and growing interest in safety engi- neering, preventive health, and health education and wellness programs. The great tradition and growing sophistication of preventive medicine at Kaiser Permanente since Dr. Garfield’s time would, I am certain, impress and gratify him. Motivated by awareness that preventable illness makes up 70 percent or more of the xiv The Lasting Legacy of Sidney R. Garfield, M.D.

total burden of illness and its associated costs, Kaiser Permanente has long embraced an expanding concept of prevention and early detection of disease that includes, in addition to such traditional practices as immunizations and periodic screenings, a broad array of health promotion and patient self-management practices. Through the Care Management Institute and our research units, we have focused on the development and diffusion of evidence-based guidelines for preventive practices and self-care for patients with chronic and complex conditions. And with the implementation of our KP HealthConnect electronic medical record, we are now capable of driving the promises of preventive medicine to an entirely new level of practice, with automated physician reminders and an array of patient-oriented health education and self-management tools. The concept of preventive care has also had great impacts across the entire health care environment. Most of the NCQA-HEDIS measures by which health care organizations are evaluated for clinical quality are actually preventive and early detection practices, as are many of the measures by which health plans and providers will be reimbursed in most of the new pay-for-performance initiatives. However, as health care costs continue to push against the limits of middle- class affordability, the importance of many preventive practices is losing ground in some significant ways. As we know from our own research, whereas some common preventive practices may be cost effective at an employer or social level (by reducing absenteeism, for instance), they may not be for the health care industry in isolation. This fact has led some insur- ers to underpay primary care physicians for preventive services. The result has been a threatened shortage of primary care physicans coming out of American medical schools. Hopefully the emergence of the “medical home” idea as a basis for enhanced payment for primary care coordination will begin to reverse this trend. Further, as noted above, early evidence from the introduction of high-deductible health plans in the U. S. suggests lower compliance with needed visits and medications for patients with chronic conditions such as diabetes and hypertension.

xv THE STORY OF DR. SIDNEY R. GARFIELD

Information Technology Were Sidney Garfield to make an appearance today, I suspect he would be aghast that so many other aspects of American life and work have enjoyed the benefits of sophisticated information systems while large portions of the health care industry remain largely stuck in the Paper Age. Having envisioned and promoted many of the great improvements that computers could bring to medicine back in the 1960s, Dr. Garfield — never a pa- tient man — would no doubt wonder why, more than four decades later, it is still not universal, and may require federal legislation and funding to be achieved. As early as 1960, Dr. Garfield embraced the idea that computers — those gi- ant punch-card machines of the period — could somehow lead to a fundamental transformation of health care delivery. He assigned the brilliant young physician Morris Collen, M.D., an internist who had a degree in electrical engineering, to look into the possibilities. As John Smillie, M.D., recounted in his history of The Permanente Medical Group, Collen reported back “to confirm that Dr. Garfield was correct: Medical electronics was beginning a period of great innovation and diffusion, and … we should begin to take advantage of the potential of electronic digital computers.”4 Remember, this was 1960. The story of Kaiser Permanente’s pioneering work with information technology under the sponsorship of Dr. Garfield and the direction of Dr. Collen is a remark- able tale. Not more than half a dozen places in the world were doing comparable research in health care. As early as 1968, Dr. Garfield could confidently write that “the computer cannot replace the physician, but it can keep essential data moving smoothly from laboratory to nurse’s station, from X-ray department to the patient’s chart, and from all areas of the medical center to the physician himself.”1 Two years earlier, Dr. Collen had declared in a speech to the Minnesota State Medical Association that “the computer will probably have the greatest impact on medical science since the invention of the microscope.”1 By 1970, when Dr. Garfield spelled out his grand vision for the future of medicine in Scientific American,5 he included a series of diagrams of the evolution of health xvi The Lasting Legacy of Sidney R. Garfield, M.D.

systems through the decades, beginning in 1900. At the center of each diagram up to 1970 was the hospital — the central axis of the system. In his diagram of the sys- tem of the future, the hospital is replaced by the “computer center” — an amazingly prescient vision for the time. He began telling his Permanente colleagues that they had all the elements of a “jet-engined plan” for health care, but without the computer and other innovations, such as health education centers and expanded use of nurse practitioners, they remained hitched to a “buggy” of traditional medical practice. Despite the many fits and starts, leaps and stumbles along the almost half century- long path to KP HealthConnect, I am certain Dr. Garfield would be proud of the organization today for the leadership it has continued to show by implementing the largest and most sophisticated health information technology system in the world at a time when much of American health care is still debating the “business case for IT.” Although Dr. Garfield would be on familiar ground with many of the capabilities of KP HealthConnect, he would have to be impressed by at least one major feature: that of rapid, asynchronous two-way communication between doctors and patients, and doctors and doctors, and the ability of patients to input data into their medical record and access information from it. In the pre-Internet era, Drs. Garfield and Collen could only glimpse the full potential of the technology to “virtualize” many elements of the physician-patient relationship, moving much of the interaction downstream in the interests of efficiency and improved service.

Conclusion As I have noted, the four great ideas on which so much of Dr. Garfield’s enduring and future reputation rests are under varying degrees of challenge today. That fact is of legitimate concern to many of us — and to many outside Kaiser Permanente, as well. But perhaps we should also look at these challenges as opportunities — something both Dr. Garfield and Mr. Kaiser were famous for doing. As Dr. Garfield told The Permanente Medical Group executive com- mittee in his annual report in 1964, “Opposition by organized medicine to

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our program was good for us. It kept us intellectually honest and stimulated us to do better continually.”1 Just as Dr. Garfield and his fellow Permanente physicians were forced by skeptics and outright powerful opponents to prove the value of group practice and prepayment, the current generation of Permanente doctors and Kaiser Foundation Health Plan leaders and employees are being challenged to bring greater proof of the value of our model to the claims and promises we make to employers and members. In meeting these challenges, we should remember that the principles that Dr. Garfield laid down almost 60 years ago are not so rigid as to be unadaptable to changing realities. In fact they have all evolved in significant ways since they were first articulated. As he warned at an interregional meeting of Permanente physician leaders in 1974: “Institutions tend to become static; they build walls around themselves to protect themselves from change and eventually die. You should fight that [tendency] by opening up your thinking and your ideas, and work for change.”1 Equally important, however, is the need to understand the contributions of each of these four principles to the evolution of what we have collectively created over the last six decades. We commonly call this Permanente Medicine. The power of prepayment to a multispecialty group practice is, in fact, the engine of Permanente Medicine, an engine that has driven and continually refreshed Kaiser Permanente through good times and bad. We should always strive to preserve and protect the power of this engine.

References 1. Gilford S. Compendium of Quotes. Unpublished manuscript, 2005. 2. Committee on the Costs of Medical Care. Medical Care for the American People: The Final Report of the Committee on the Costs of Medical Care. Chicago: University of Chicago Press, 1932. 3. Gillies R, Chenok KE, Shortell SM, Pawlson G, Wimbush JJ. The impact of health plan delivery system organization on clinical quality and patient satisfaction. HSR: Health Services Research 2006 Aug;41(4) Part 1:1181-99. 4. Smillie J. Can physicians manage the quality and cost of health care? New York: Mcgraw-Hill; 1991. 5. Garfield SR. The delivery of medical care. Sci Am 1970 Apr;222(4):15-23.

Adapted, updated, and edited by Jay Crosson, MD, from The Permanente Journal 2006 Summer, 10(2), Crosson J. Dr. Garfield’s Enduring Legacy — Challenges and Opportunities, p 40-5; copyright 2006, with permission from The Permanente Press. xviii Preface

Henry J. Kaiser is the name most often associated with Kaiser Permanente, the medical care program that was, in his own view, his greatest achievement. He once said, “I only expect to be remembered for … filling the people’s greatest need: good health.” He also was always careful to acknowledge that he could never have done what he did in health care without his co-founder, surgeon Sidney R. Garfield, M.D. It was Garfield, starting in the 1930s, who collected three ideas into a single system of medical care: prevention of illness, group medical practice, and facilities under one roof. Garfield advocated for a not-for-profit foundation as the basic financing structure and believed that ideas from academic medical centers — in- cluding the linkage of research to care delivery — could be part of a health care program for average patients, not just the elite. In 1938, Henry Kaiser met Garfield for the first time, listened to his ideas, and declared, “Young man, if your ideas are half as good as you say they are, they are good for the entire country.” In 2003, when Kaiser Permanente created the Heritage Resources Department and started its historical archive, there was a manila folder marked “Sidney R. Garfield” with a paltry amount of material, perhaps a quarter inch thick. Fortunately, archivist Bryan Culp soon joined the department and turned that small file into a still-growing mountain of documentary material. Today, our archive holds thousands of pages of Garfield’s own words: papers, speeches, interviews, surgical notes, and more. For the first time, a comprehensive collection of invaluable original research material exists about the life, ideas, and contributions of Sidney Garfield.

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This book is based upon these collected and reassembled documents — his own and others relating to him. It represents the first time that Garfield’s story has been told in a form that puts him in the foreground and Henry Kaiser in the background. This is not, however, a definitive biography — that awaits the work of some future scholar and medical historian. In the following pages I have tried to offer readers a story that provides a comprehensive overview of Garfield’s life and contributions. To that end, I chose to use a narrative style uncluttered by footnotes. I am, however, appending a list of works authored and coauthored by Sidney R. Garfield that can be found in the Kaiser Permanente Heritage Archive. These are the specific materi- als upon which I drew for this story. It is important to point out that every direct quotation in the book is real; I engaged in no literary license. Likewise, every factual statement made here is rooted in one or more reliable historical sources. Many people deserve thanks for their contributions to this work. Bryan Culp’s dedication to finding and archiving materials has, as noted, created the first and only comprehensive collection of Garfield history, now preserved for future research. Steve Gilford, a consulting historian to our archive, spent many years collecting materials and photographs relating to Kaiser Permanente history, often rooting through trash or recy- cling bins and eBay to salvage and preserve valuable documents. He interviewed scores of individuals with intimate recollections of many of the events recounted here. He also provided excellent commentary and fact-checking on early drafts. Jon Stewart, Com- munications Director for Government Relations and Health Policy at Kaiser Foundation Health Plan, Inc., deserves special thanks for editing the manuscript, making sense of convoluted passages in the first draft, and for significant rewrites and revisions. Thank you to Max McMillen for editing services and Virginia McPartland for her help with proofreading. Special gratitude goes to the Regional Oral History Office at The Bancroft Library of the University of California at Berkeley, where past and present scholars and oral historians have been documenting the history of Kaiser Permanente. Thank you, too, to Tom Janisse, M.D., publisher of The Permanente Press, for his support. — Tom Debley, Director, Heritage Resources, Kaiser Permanente xx Prologue The Desert Doctor

It was an inauspicious beginning — as it would have been for any new physician, let alone a young man of great vision and ambition. The year was 1933, four years into the despera- tion of the Great Depression. Sidney R. Garfield, having com- pleted his surgical residency at Los Angeles County General Hospital, launched his medical career by leaving the growing metropolis and constructing a compact, 12-bed hospital in the southern end of the desolate Mojave Desert east of Los Angeles, California. His father, Isaac, helped the 27-year-old with a $2,250 loan, about $35,000 in today’s dollars. His pro- saically named Contractors General Hospital, a mile or so off the then new, two-lane transcontinental U.S. Highway 60, was about halfway between Los Angeles and Phoenix. The nearest town, a roadside outpost called Desert Center, was about six Sidney Garfield at his 12-bed miles to the east. The locale, as described by one observer, was a “hot, dusty region Contractors General never meant by God for human activity or habitation.” Hospital, 1935. With jobs almost impossible to find, even in medicine, Garfield looked to this remote spot when he learned about construction of the Metropolitan Water District of Southern California’s aqueduct designed to bring Colorado River water

1 THE STORY OF DR. SIDNEY R. GARFIELD

to Los Angeles. Thousands of men were laboring under dangerous and physically demanding con- ditions in the harsh desert environment. Garfield reasoned they would need on-site medical care.

Sidney Garfield Desert Center had been founded about a dozen catching up on his paperwork at years earlier by an itinerant preacher and cotton Contractors General Hospital, 1933. farmer at a spot where his car had broken down. It was an aptly named dusty and lonely wide spot on the highway where a traveler could get a meal at the 24-hour café, buy gas, and refill the canvas water bags to use if the car engine overheated while crossing the desert. It was about 50 miles east of Indio, the largest city in the region, where Dr. Gene Morris, former intern at Los Angeles County General Hospital, had grown up and had returned to set up a medical practice. Morris told his friend Garfield about the construction project with thousands of aqueduct workers covered by California’s progressive system of workers’ compensation, but with no medical or hospital care available near their work camps. The two young doctors formed a partnership and built their wood- frame hospital on the edge of a construction camp. Garfield named it Contractors General Hospital and ensured that it was modern and well-equipped with creature comforts, including air conditioning — an innovation installed in the White House in 1930 but not in widespread use, especially not in rural hospitals. With 5,000 aqueduct construction workers now at jobsites spread across 150 miles of desert, getting patients, they figured, would not be a problem. The two young doctors were gambling that on-the-job injuries alone would bring them plenty of patients insured for industrial accidents — enough to make the hospital an economic success. They were right. Men suffering from on-the-job injuries did come, but Contractors General tended to get only the relatively minor cases. Insurance companies shipped serious cases — the ones that provided the most significant income — to hospitals in Los Angeles. To make matters worse, the

2 THE DESERT DOCTOR

insurance companies discounted the physicians’ bills for the care they did give, claiming they over-treated patients. “We got a patient,” Garfield explained, “and we would treat him with tender loving care and we would bill the insurance company, and more often than not, they would come back and discount our bills, saying that we treated the patient too many times.” Even when the insurance companies did pay, they were slow in paying. Another problem arose when the aqueduct workers came in with all sorts of illnesses clearly not covered by their workers’ compensation insurance, including venereal diseases from prostitutes who also set up shop near the work camps. "at would not have been a problem, except that few of the men could pay their medical bills. "e cost of treating non-paying patients soon put a major financial strain on the busy little hospital. Discouraged, Dr. Morris sold his share of the partnership to Garfield. Garfield was now on his own, with just one nurse, a housekeeper/cook, and her husband, who served both as orderly and ambulance driver. As if non-paying patients, slow- paying insurers, rattlesnakes, scor- pions, and scorching summer temperatures that rarely dipped below triple digits were not discour- agement enough, a new threat to his struggling enterprise arose. One day a sedan turned off Highway 60 in a cloud of dust and headed up the dirt road toward Contractors

General. Two men got out and An unidentified orderly standing beside what identified themselves as representatives of a finance company. "ey had come to is believed to be Sidney Garfield’s first seize Garfield’s Ford panel truck, which had been outfitted as an ambulance. ambulance. Garfield had not been able to afford an ambulance, and a local undertaker in Indio had offered him a deal: He would rent the ambulance to Garfield for $25 a

3 THE STORY OF DR. SIDNEY R. GARFIELD

month if Garfield would help him get undertaking work from the aqueduct project. But after more than a year, there had been few deaths. "e unhappy undertaker wanted out of the ambulance lease, so he went to a finance company in nearby Riverside, took out a loan using the ambulance as collateral, and then neglected to make the payments. When the fi- nance company complained, he told them to repossess the ambulance. Without an ambulance to pick up the sick and injured, the hospital would be out of business. Desperate, Garfield telephoned an attorney- friend in Los Angeles, who called the finance company’s attorney. "e finance company called off the repo

Sidney Garfield on the men, who drove away leaving a very steps of Contractors General Hospital with relieved Garfield in their dust. "e victory was short-lived. "e next day, the repo the legendary rifle used in the encounter with the men returned and again demanded the vehicle. Garfield again called his attorney, ambulance repo men. who said, “No, don’t let them do it. "ey can’t take it away.” Garfield hung up the phone, went outside, reached through the window of the ambulance and yanked the key out of the ignition. Now unable to start it, the repo men tied a rope to the ambulance’s front bumper to tow it away. Garfield slashed the rope with a knife. When they started to retie the rope, Garfield called to a staff member to bring out the rifle they used for recreational target practice. “Go ahead and shoot,” said one of the men defiantly, calculating that a physi- cian would not pull the trigger. “"ey had me stumped there,” Garfield said later. Instead, he again sliced the rope. Finally, the men left, again without the ambulance. But they reappeared two days later with the county sheriff, who carried a warrant for Garfield’s arrest for assault with a deadly weapon. "e sheriff, a good friend of Garfield’s, explained he

4 The Desert Doctor

had no choice but to take Garfield to jail because of the warrant. His plight had gone from bad to worse. The ambulance was gone, and Garfield, if convicted of assault with a deadly weapon, could lose his medical license. Fortunately, he rejected his first attorney’s advice to plead guilty and pay a fine. With a second attorney, he instead went to trial and won a not-guilty verdict. But being found not guilty was not enough for Garfield, whose honor and reputation were at stake. He sued the undertaker, the finance company, and their attorney for malicious prosecution and won. He was awarded $3,000, a portion of which he promptly used to finance a new ambulance. The ambulance incident was, in some ways, emblematic of the first phase of Garfield’s extraordinary career — the daring desert years of creating something from nothing, of struggling against daunting odds to achieve his ends. Given his determination to succeed, whatever the obstacles, he exhibited a characteristic refusal to allow second thoughts to give him pause. Indeed, Garfield, in these early years, had a vague sense he was working toward something larger than personal success. Today, across the road from old U.S. Highway 60 and the still operating Desert Center Café, where Garfield could celebrate his legal victory with a 50-cent roast beef dinner, stands California Historical Marker No. 992, in Garfield’s honor, to announce to occasional visitors that something very special and enduring was born in this lonely corner of the desert.

California Historical Marker No. 992 at Desert Center, about six miles east of the site of Contractors General Hospital.

5 THE GREAT DEPRESSION AND “SOCIAL MEDICINE”

group medical practice — a form of physician organization and cooperation that the AMA still equated with socialism. “We recognized,” said Kay, “the importance of being able to provide all necessary medical studies and treatment with no economic barri- ers. We also appreciated the fact that we were able to develop professionally through sharing patients and learning from the other physicians with whom we worked.” Garfield later made the case for the virtues of group practice to physicians in Portland, Oregon, when he told a meeting of the Multnomah County Medical As- sociation in 1945: “It has always been a paradox that group practice is the method used to teach medicine of the highest type — all university medical schools are group practice operations — yet the individual physician is taught to go into solo practice. Group practice is essential because as medical knowledge increases in mass and complexity, no one doctor can learn the entire field … "is produces both quality and economy. Quality, because the doctors participating are specialists, because consultation is easy, and because of the stimulus resulting from working with well-trained [physicians] in various fields. Economy results from the use of common facilities, records, office space, and equipment, and elimination of waste of travel.” But perhaps most important was the power this could bring to preventing illness. Sidney Garfield performing surgery, It was here that Garfield summed things up from a patient point of view in a simple probably during his time as the so-called phrase, “"e people of this country … don’t want to get sick.” “Super Resident” at Los Angeles County It was with some irony, then, that the medical establishment saw Garfield’s General Hospital. vision of widespread group medical practice as unethical and socialistic when Gar- field saw it as an extension into the community of the university teaching hospital model, bluntly telling the annual meeting of the AMA in Chicago (Appendix 1)

15 THE STORY OF DR. SIDNEY R. GARFIELD

support the American fighting force. Sidney Garfield was among them, immediately enlisting with the 73rd Evacuation Hospital organized by USC’s volunteer clinical faculty. First Lieutenant Garfield, who because of an allergy to wool was outfitted at his own cost in a custom-tailored Army uniform, reported to his mentor, Dr. Berne — now Colonel Berne. "ey prepared to ship out for Burma. Meanwhile, on the eastern shore of San Francisco Bay, in the sleepy little town of Richmond, Clay Bedford, who had worked for his old friend Edgar Kaiser as chief engineer on the Grand Coulee Dam, was running a new shipyard built by Henry Kaiser. "e Kaiser Company had a head start on the American Home Front war, having begun building ships for the British before the attack on Pearl Harbor. "e Permanente Metals Corporation, the business entity that ran the Kaiser Shipyards, would quickly expand to four yards and employ almost 100,000 workers, turning Richmond — just a dozen miles north of Kaiser’s headquarters in Oakland — into an overnight boomtown. Edgar Kaiser was mounting an identical effort on the Columbia River at Vancouver, Washington, and then across the river in Portland, Oregon. In Fontana — a Southern California desert community 45 miles east of Los Angeles — Henry Kaiser was building his own mill to produce steel for the ships. Among the early shipbuild- ers in both Richmond and Vancouver were workers who came from the Coulee job, along with heavy equipment Home Front that was moved from Coulee shipbuilders during a shift change in and adapted for shipbuilding. the Richmond Kaiser Shipyards, As a Kaiser executive once de- now one of the sites of the Rosie scribed the company’s wartime the Riveter / World War II Home shipbuilding attitude: “A ship Front National Historical Park. was nothing but a dam that wouldn’t stay put.” By the end

36 FDR TO GARFIELD: “YOU’RE NOT IN THE ARMY NOW!”

Kaiser West Coast Shipyards launched a ship a day and broke all shipbuilding records. Here (top) a prefabricated deckhouse is hoisted into place in Portland, while a ship (bottom) is launched at Richmond.

It fell to Sidney Garfield and the doctors, nurses, and other staff he hired to keep the shipyard workers healthy as they opened the Permanente Health Plan in 1942.

47 TOWARD TAHOE: CRISES AND CROSSROADS

Center of Excellence for Culturally Competent Care for members with disabilities. (Henry Jr. died in 1961 at age 44, having maintained a busy and active career that included spearheading Kaiser Permanente’s first forays into public relations.) Garfield’s growing emotional bond with Kaiser Sr. intensified still further when Bess Kaiser, who had been suffering for years with chronic high blood pressure, began to grow weaker with the added complication of progressive kidney failure. Although Garfield knew her condition was probably terminal, he sent cardiology and renal disease specialists in search of the latest treatments during the final months of her life. At Garfield’s request, Dr. Cutting, the future executive director of "e Permanente Medi- cal Group, took a leave of absence from his surgical duties at the Oakland hospital and actually moved into the Kaisers’ penthouse overlooking Lake Merritt in downtown Oakland to care for Bess. Garfield also asked a nurse at the Permanente Hospital, Alyce Chester, to move in to provide nursing care for Mrs. Kaiser. Described by those who knew her as a brilliant nurse, Chester had joined the staff during the war years. She was an at- In 1952, Sidney Garfield and Henry tractive woman, divorced, and the mother of a young son, Michael. Garfield had Kaiser review a model of the controversial mentored her and, impressed with her abilities, made her a part of his executive Walnut Creek hospital and renderings of the team and increasingly came to rely on her. However, his decision to have Chester Los Angeles and San care for Bess would prove far more fateful than he could have imagined. Francisco hospitals. With Mrs. Kaiser’s needs attended to with expert 24-hour care, Garfield was busy on another front. To handle the medical needs of the burgeoning number of health plan members in California, he made plans for the expansion of the Oakland and Vallejo hospitals and construction of two new, 210-bed hospitals — the first in Los

77 Bibliography

Bibliography

Allen, Terri Ann. SCPMG ... The First Fifty Years: History of the Debley, Tom. “KP HealthConnect: Fulfilling the Vision of KP’s Southern California Permanente Medical Group, 1953-2003. Los Founding Physician.” The Permanente Journal8, no. 4 (2004):32-3. Angeles: Southern California Permanente Medical Group, 2003. ———. “Think the Unthinkable, Dream the Impossible.” An ad- Barton, Jane. “Good Nursing Is Core of Panorama Plan.” The dress delivered at The History of Medicine Society at The Oregon Modern Hospital 99 November 1962: 86-91. Health & Science University, Portland, OR, January 2006. Bolotin, Sally. Interview by Steve Gilford, Sherman Oaks, CA, de Kruif, Paul. Kaiser Wakes the Doctors. New York: Harcourt August 29, 2006. Brace, 1943. Breslow, Lester. A Life in Public Health: An Insider’s Retrospective. ———. “Tomorrow’s Health Plan–Today!” Reader’s Digest, May New York: Springer Publishing Co., 2004. 1943, 61ff. Cadman, Paul F. Manuscript. “The Builder: The Life and Work ———. “Many Will Rise and Walk.” Reader’s Digest, February of Henry J. Kaiser.” Kaiser Permanente Heritage Resources 1946, 79 ff. Archive, Oakland, CA. ———. Life Among the Doctors. New York: Harcourt Brace, 1949. Champion, Hale. “Health Plan Controversy: How the New Kaiser Dusheck, George. “Henry Kaiser’s Big Medicine Is Now Fifteen Hospital Works.” San Francisco Chronicle, February 14-16, 1954. Years Old.” San Francisco News, October 29, 1957. ———. “Henry J. Kaiser: New Kind of Medicine Man.” The Engel, Jonathan. Doctors and Reformers: Discussion and Debate Progressive June 1954: 21ff. Over Health Policy, 1925-1950. Columbia, SC: University of Collen, Morris F., ed. Multiphasic Health Testing Services. New South Carolina Press, 2002. York: John Wiley & Sons, 1978. Fleming, Scott. “Evolution of the Kaiser-Permanente Medical ———. “History of the Kaiser Permanente Medical Care Care Program: An Historical Overview.” Kaiser Permanente Program,” an Oral History Interview Conducted in 1986 by Sally Heritage Resources Archive, Oakland, CA, 1982. Smith Hughes. Berkeley, CA: Regional Oral History Office, The ———. “History of the Kaiser Permanente Medical Care Pro- Bancroft Library, University of California, Berkeley, 1988. gram,” an Oral History Interview Conducted in 1990 and 1991 by Cutting, Cecil C. “History of the Kaiser Permanente Medical Sally Smith Hughes. Berkeley, CA: Regional Oral History Office, Care Program,” an Oral History Interview Conducted in 1985 The Bancroft Library, University of California, Berkeley, 1997. by Malca Chall. Berkeley, CA: Regional Oral History Office, The Foster, Mark S. Henry J. Kaiser: Builder of the Modern American Bancroft Library, University of California, Berkeley, 1986. West. Austin: University of Texas Press, TX, 1989. Cutting, Cecil C., and Morris F. Collen. “A Historical Review Fowler, Dan. “More Care for Less Money: Henry J. Kaiser’s Medical of the Kaiser Permanente Medical Care Program.” Journal of the Plan.” Look, Sept. 9, 1952, 73-5. Society for Health Systems, 3, no. 4 (1992): 25-30. ———. “Push-Button Hospital.” Look, December 15, 1953, 92 Daniels, Mark. “The Permanente Foundation Hospital.” Architect passim. and Engineer May 1945, 10ff. Gilliam, Harold. “A Revolutionary Medical Plan Comes to the Davies, Lawrence E. A World War II Diary. Hat Creek, CA: HiS- Waterfront.” San Francisco Chronicle, July 15, 1951. tory Ink Books, 1994.

133 THE STORY OF DR. SIDNEY R. GARFIELD

Han, Paul K. J. “Historical Changes in the Objectives of the ———. “Lessons and Parables in Health Care: A Tale of Two Periodic Health Examination.” Annals of Internal Medicine, 127, Cities.” The First Annual Ernest W. Saward Lecture. Portland, no. 10 (November 1997): 910-7. OR: Kaiser Permanente Center for Health Research, 1989. Heiner, Albert P. Henry J. Kaiser: Western Colossus. San Francisco: Shelby, Betty. “The Modern Hospital of the Month [Kaiser Halo Books, 1991. Foundation Medical Center, Honolulu, HI]: Central Work Corridor Simplifies Nurses’ Work.”The Modern Hospital93 Hendricks, Rickey. “Medical Practice Embattled: Kaiser Perma- (December 1959): 65-70. nente, the American Medical Association, and Henry J. Kaiser on the West Coast, 1945-1955.” The Pacific Historical Review,60, Smillie, John G. “History of the Kaiser Permanente Medical no. 4 (November 1991): 439-73. Care Program,” an Oral History Interview Conducted in 1985 by Ora Huth. Berkeley, CA: Regional Oral History Office, The ———. A Model for National Health Care: The History of Kaiser Bancroft Library, University of California, Berkeley, 1987. Permanente. New Brunswick, NJ: Rutgers University Press, 1993. ———. Can Physicians Manage the Quality and Costs of Health Kaiser, Henry J. Address to Physicians at the St. Francis Hotel, Care? The Story of the Permanente Medical Group. New York: San Francisco, CA, June 9, 1948. McGraw-Hill, 1991. ———. “The New Economics of Medical Care.” An address to Somers, Anne R., ed. Kaiser-Permanente Medical Care Program: the National Press Club, Washington, D.C., May 26, 1954. One Valid Solution to the Problem of Health Care Delivery in the Kay, Raymond M. Historical Review of Southern California Per- U.S. A Symposium. New York: The Commonwealth Fund, 1971. manente Medical Group: Its Role in the Development of the Kaiser Starr, Kevin. Embattled Dreams: California in War and Peace, Permanente Medical Care Program in Southern California. Los 1940-1950. Oxford: Oxford University Press, 2002. Angeles: Southern California Permanente Medical Group, 1979. Starr, Paul. The Social Transformation of American Medicine. New ———. “History of the Kaiser Permanente Medical Care York: Basic Books, 1982. Program,” an Oral History Interview Conducted in 1985 by Ora Huth. Berkeley, CA: Regional Oral History Office, The Bancroft U.S. House Committee on Interstate and Foreign Commerce. Library, University of California, Berkeley, 1987. Henry J. Kaiser. “A Private Enterprise Solution to Medical Care by the Doctors of this Country.” 83rd Cong., 2nd Sess., January Keene, Clifford H. “History of the Kaiser Permanente Medical 11, 1954. Care Program,” an Oral History Interview Conducted in 1985 by Sally Smith Hughes. Berkeley, CA: Regional Oral History Office, Velie, Lester. “Supermarket Medicine.” The Saturday Evening The Bancroft Library, University of California, Berkeley, 1986. Post, June 20, 1953, 22 passim. Kuh, Clifford. “The Permanente Health Plan for Industrial War Manpower Commission. Physical Demands and Capacities Workers.” Industrial Medicine 14, no. 4 (April 1945): 3 ff. Analysis. San Francisco and Oakland: War Manpower Commis- sion and Permanente Foundation Hospitals, 1944. Lane, Frederick C. Ships for Victory: A History of Shipbuilding Under the U.S. Maritime Commission in World War II by Frederick Weeks, Lewis E. ed. Ernest W. Saward, In First Person: An Oral C. Lane with the Collaboration of Blanche D. Coll, Gerald J. History. Hospital Administration Oral History Collection. Chi- Fischer, David B. Tyler, and Joseph T. Reynolds. Baltimore: Johns cago: American Hospital Association, 1987. Hopkins University Press, 2001. Williams, Greer. “Kaiser.” Modern Hospital 116 (February 1971): Lindbergh, Alma. Manuscript. “History of the Kaiser Orga- 67-95. nizations.” Kaiser Permanente Heritage Resources Archive, Wolf, Donald E. Big Dams and Other Dreams: The Six Companies Oakland, CA. Story. Norman, OK: University of Oklahoma Press, 1996. Martin, Helen Eastman. The History of the Los Angeles County Yedidia, Avram. “History of the Kaiser Permanente Medical Care Hospital (1878-1968) and the Los Angeles County-University of Program,” an Oral History Interview Conducted in 1985 by Ora Southern California Medical Center (1968-1978). Los Angeles: Huth. Berkeley, CA: Regional Oral History Office, The Bancroft University of Southern California Press, 1979. Library, University of California, Berkeley, 1987. Ordway, Alonzo B. Interview by Dan Scannell, Oakland, CA, 1967. Zoloth, Laurie. “The Best Laid Plans: Resistant Community and Saward, Ernest, W. “History of the Kaiser Permanente Medical the Intrepid Vision in the History of Managed Care Medicine.” Care Program,” an Oral History Interview Conducted in 1985 by Journal of Medicine and Philosophy, 24, no. 5 (1999): 461-491. Sally Smith Hughes. Berkeley, CA: Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 1986.

134 Selected Works

Selected Works Authored or Coauthored by Sidney R. Garfield, M.D.

Collected together for the first time, the Sidney ———. “The Essential Features Of The Kaiser Plan.”Journal of the American Medical Association 125 (1944): 188. R. Garfield, M.D. Papers at the Kaiser Permanente ———. “Health Plan Principles in the Kaiser Industries.” Heritage Resources Archive support research into Gar- Journal of the American Medical Association 126, no. 6 (1944): field’s role as co-founder of Kaiser Permanente and his 337-9. contributions to the theory and practice of health care ———. “First Annual Report of Permanente Foundation delivery systems. These papers are available for review Hospital.” Permanente Foundation Medical Bulletin, II, no. 1 (January 1944): 35-48. at the Heritage Resources Archive by appointment. ———. “Address to the Multnomah County Medical Associa- tion.” Portland, OR, April 4, 1945. Collen, F. Bobbie, Robert Feldman, Krikor Soghikian, and Sidney R. Garfield. “The Educational Adjunct to Multiphasic Health ———. “Group Medicine: A Discussion of the Economics of Testing.” Preventive Medicine 2, no. 2 (June 1973): 247-60. Medical Care—It Works at Permanente.” Modern Hospital 45 (November 1945): 53-5. Collen, Francis Bobbie, Blanche Madero, Krikor Soghikian, and Sidney R. Garfield. “Kaiser Permanente Experiment in Ambulatory ———. “The Plan That Kaiser Built.”Survey Graphic, Decem- Care.” American Journal of Nursing 71, no. 7 (July 1971): 1371-4. ber 1945, 480-2. Collen, Morris F., Sidney R. Garfield, and James H. Duncan. ———. “A Report on Permanente’s First Ten Years.” Permanente “The Multiphasic Checkup for Evaluation of Well People.” In Foundation Medical Bulletin X, nos. 1-4 (August 1952): 1-11. Challenges and Prospects for Advanced Medical Systems. Miami: ———. Statement of Sidney R. Garfield Concerning Protection Symposia Specialists, 1978. Against Catastrophic Diseases. U.S. House Committee on Inter- state and Foreign Commerce. Sidney R. Garfield. Washington, Collen, Morris F., S. R. Garfield, Robert H. Richart, James H. rd nd Duncan, and Robert Feldman. “Cost Analyses of Alternative DC. 83 Cong., 2 Sess., January 6, 1954. Health Examination Modes.” Archives of Internal Medicine 137, ———. “The Kaiser Foundation Health Plan.”The Prescriber, no. 1 (January 1977): 73-9. November 1954. Feldman, R., S. L. Taller, Sidney R. Garfield, and others. “Nurse ———. “Kaiser Foundation Health Plan.” Remarks before the Practitioner Multiphasic Health Checkups.” Preventive Medicine California State Assembly Interim Committee on Finance and 6 (1977): 391-403. Insurance, San Francisco, November 3-4, 1955. Garfield, Sidney R.Papers . Kaiser Permanente Heritage Re- ———. “Address by Sidney R. Garfield, M.D., Kaiser Founda- sources Archive, Oakland, CA. tion Hospitals of Northern California Fifteenth Anniversary.”

135 THE STORY OF DR. SIDNEY R. GARFIELD

Commemorative address on the occasion of the fifteenth an- ———. “Health Care and Health Services Resources.” Medical niversary of Kaiser Foundation Hospitals of Northern California, Progress Through Technology 1, no. 1 (March 1972): 2-6. Berkeley, CA, October 19, 1957. ———. “A New Medical Care Delivery System Model.” In Pro- ———. Address to the Kaiser Foundation Hospitals Panel, the ceedings of an International Conference on Health Technology Monterey Management Conference, Monterey, CA, May 11, Systems, San Francisco, CA, November 14-16, 1973. 1960. ———. “The Computer and New Health Care Systems.” In ———. Address to the Pack Forest Conference, the University Hospital Computer Systems. New York: John Wiley & Sons, 1974. of Washington, Seattle, WA, October 3, 1964. ———. Interview by Daniella Thompson. Oakland, CA, 1974. ———. “Medicine of the Future.” Address to the Staff Educa- ———. “Health Evaluation’s Great Promise for Medical Care of tion Conference for Physicians, San Mateo, CA, October 31, the Future.” Address, audience unknown, November 5, 1974. 1965. ———. “The Potential Opportunities of Systemized Prepaid ———. “Rationally Organized Medicine.” Draft, audience Care.” In Health Handbook: An International Reference on Care unknown, November 16, 1966. and Cure. Amsterdam: North-Holland Publishing Co., 1976. ———. Address to the Medical Entities Management As- ———. “Evolving New Model for Health Care Delivery.” sociation, Kaiser Foundation Hospitals of Southern California, Orthopaedic Review 5, no. 3 (March 1976): 19-21. February 1969. ———. Remarks upon receiving an award from the American ———. “Where Goes the Kaiser Foundation Health Plan?” Ad- Planning Society at the American Hospital Association Annual dress to the Permanente Physician Orientation Communications Meeting, Anaheim, CA, August 26, 1977. Session, Oakland, CA, October 3-4, 1969. ———. Remarks on receiving the Lyndon Baines Johnson ———. Address to the Group Health Association of America Foundation Award, New York, October 27, 1977. Annual Luncheon, American Public Health Association, Phila- delphia, PA, November 12, 1969. ———. “Facilities Design and Construction.” In Multiphasic Health Testing Services. New York: John Wiley & Sons, 1978. ———. “The Delivery of Medical Care.”Scientific American 222, no. 4 (April 1970): 15ff. ———. Interview by Dan Scannell. Audio-video recording. Oakland, CA, 1978. ———. “Kaiser Permanente’s Prepaid Plan.” Address to the Utah State Medical Association, Salt Lake City, UT, September ———. “Health of a Nation.” Address at Riva de Gauda, Italy, 9, 1970. April 1978. ———. “What We Must Do Before National Health Insurance.” ———. “Health Testing – A New Concept of Health Care De- Medical Economics, October 12, 1970. livery.” In Health Handbook: An International Reference on Care and Cure. Amsterdam: North-Holland Publishing Co., 1979. ———. “Multiphasic Health Testing and Medical Care as a Right.” New England Journal of Medicine 283, no. 20 (November ———. Address at WellCare Systems of the Future, 12, 1970): 1087-9. Saltsjobaden, Sweden, May 1979. ———. “New Trends in a Health Care System.” Address to the ———. Remarks on receiving an award from the American As- AMA Symposium on Computer Systems in Medicine, Las Vegas, sociation for Hospital Planning, August 25, 1979. NV, February 16-17, 1971. ———. “A Rational Care Model for Health Care of a Nation.” ———. “Free Care Concept May Overload U.S. Health Ser- In Lecture Notes in Medical Informatics: Technology and Health: vices.” Geriatrics 26, no. 4 (April 1971): 41 passim. Man and His World. Berlin: Springer-Verlag, 1980. ———. “An Ideal Nursing Unit.” Hospitals: Journal of the Ameri- ———. Interview by Joan Trauner, Oakland, CA, not dated, c. can Hospital Association 45, no. 12 (June 16, 1971): 80-6. 1981. ———. “Prevention of Dissipation of Health Services Re- ———. “50 Years With HMO’s.” Private Practice, April 1981. American Journal of Public Health sources.” 61, no. 8 (August ———. Address to the 55th Annual Medical Group Manage- 1971): 1499-1506. ment Association Conference, New Orleans, LA, October 13, ———. “A Clear Look at the Economics of Medical Care.” Ad- 1981. dress to the symposium Technology and Health Care Systems in ———. “Keynote Address to the IHEA ’82: New Primary Care the 1980s, San Francisco, CA, January 19-21, 1972. Delivery Systems.” Medical Informatics 7, no. 3 (1982): 165-8.

136 Selected Works

———. Interview by Mimi Stein, Oakland, CA, February 17, Garfield, Sidney, Cecil Cutting, and Morris Collen. “Histori- 1982. cal Remarks Presented to the Executive Committee.” Address delivered at the TPMG Executive Committee, Oakland, CA, ———. “The Coulee Dream: A Fond Remembrance of Edgar April 24, 1974. Kaiser.” KP Reporter, January 1982. Garfield, Sidney R. and Clarence Mayhew. “The Modern Hospi- ———. Address on the subject of “Total Health Care” at Coto tal of the Month: Walnut Creek Hospital; Efficiency Centers on de Caza, CA, December 10, 1982. the Corridor.” The Modern Hospital 82 (March 1954): 61-72. ———. “Worthy of Being Copied.” Address to the Kaiser The Permanente Medical Group.Manuscripts . Kaiser Permanente Family Foundation Board of Trustees, [Oakland, CA], June 26, Heritage Resources Archive, Oakland, CA. 1983. Richart, Robert H., James H. Duncan, Sidney R. Garfield, and ———. “The Delivery of Medical Care.”Scientific American Morris F. Collen. “An Evaluation Model for Health Care System 222, no. 4 (April 1970): 15ff. Reprint,M.D. Computing. 11, no. Change.” Journal of Medical Systems 1 (1977): 65-77. 1 (Jan-Feb 1994): 43-7. Weeks, Lewis, ed. Sidney R. Garfield in First Person: An Oral His- Garfield, Sidney R., Morris F. Collen, Robert Feldman, Krikor tory. Hospital Administration Oral History Collection. Chicago: Soghikian, Robert H. Richart, and James H. Duncan. “Evalu- American Hospital Association, 1974. ation of an Ambulatory Medical-Care Delivery System.” New England Journal of Medicine 294, no. 8 (February 19, 1976): 426-31. Garfield, Sidney R., Cecil Cutting, Robert Feldman, Stephen Taller, and Morris F. Collen. Total Health Care Project: Final Report. 2 vols. Oakland, CA: Permanente Medical Group, Inc., 1987.

137 Index

Index

Accident prevention, in health care economics, American Home Front war, 36, 37 Bashta, Pete, 31 20-21. See also Prevention American Medical Association (AMA), 12, 15 Bashta, Yvonne, 31 Adequate facilities, xiii. See also Facilities Canon of Ethics, 30 Battin High School, Sidney Garfield at, 8-9 in health care systems, 128 group medical practice and, 15-16 Bay Area. See San Francisco transforming modern medicine via, 50, 110, 114 opposition to Permanente Health Plan from, Bedford, Clay, 36, 37, 68 Administrators, in hospital design, 90 57-58, 59, 63-64, 65 Beds, in Kaiser hospitals, 89, 113 Advances in medicine, Permanente Foundation Sidney Garfield’s 1944 speech to, 15-16, Belmont, California, Kaiser hospital at, 113 and, 69-70 51-52, 109-111 Berkov, Bernard B., 74 Advertising/promotion, of medical services, 63, 64 versus Morris Fishbein, 66 Berman, Phoebus, 13, 35 Advice, in hospital design, 90 American Public Health Association, 72 Berne, Clarence “C. J.,” 14, 29 Affordability, of group practice, 32-33 Annals of Internal Medicine, 74 during World War II, 34, 36, 38 African-American workers, World War II health Antitrust lawsuits, versus opposition to Permanente Bill collection problems, in medical economics, 18-19 care program for, 39 Health Plan, 58 Blind faith, limitations of, 118 Aging, multiphasic testing program and, 98. See Aqueduct construction workers Blue Cross plans, 109, 115, 125 also Geriatric problems health care economics revolution and, 17-21 Board of Directors of TPMG, Sidney Garfield’s Air conditioning, as hospital innovation, 2, 27 Sidney Garfield’s treatment of, 2-3 address to, 117-119. See also The Alameda County, Permanente Foundation Architecture Permanente Medical Group (TPMG) organized in, 68 modern hospital, 86-91 Bogart, Humphrey, 28 Alameda County Central Labor Council, of Permanente hospitals, 75 Bolotin, Sally, 35, 38 Permanente Health Plan for, 55-56 as possible career for Sidney Garfield, 8-9 in Home Front medical health care program, Alameda County Medical Association, Kaiser of Walnut Creek hospital, 77, 80 39-40, 41, 45 lawsuit against, 79 Arrowhead Springs Hotel, 28, 29 Bonneville Dam, 25 Alameda County Medical Association Ethics Atkeson, Ray, 46 Boston, Sidney Garfield’s parents near, 6 Committee, opposition to Permanente Authorities, in American health care, 109 Breslow, Lester, on public health, 71-72 Health Plan from, 59-66, 79 Automated multiphasic health testing, 101 Bridges, Harry, 56 Alameda Naval Air Station, Permanente Health Automated Multiphasic Health Testing (AMHT) union membership in Permanente Health Plan Plan for, 55 facility, 93, 94, 96-99 and, 70-71, 74 “All-electric city,” 26 Award for Significant Contribution in the Field of Burma, 37, 67 Allen, Pat, 19 Health Care Delivery, 100, 107 Business professionals, at Kaiser Permanente, 83 Alvarez, Walter C., 87 Ayers, Lew, 34 AMA House of Delegates, 66. See also American Medical Association (AMA) Califano, Joseph A., 107 Ambulance, problems with, 3-5 Baby care, 101 California, 118, 119, 124, 130 America, soaring health care costs in, 12. See also “Baby in the Drawer” concept, in Kaiser hospitals, group medical plans for, 53-54, 55-56 United States 88-89 interregional planning conference in, 115-116 American Broadcasting System, 87 Baehr, George, 107 opposition to Permanente Health Plan and, 58, American health care Bancroft Library, xx 60, 63-64 delivery of, 120-131 Bank of America, in financing Kaiser hospitals, public health in, 71-72 prepaid group practice and excellence of, 41-42, 43 California Historical Marker #992, 5 109-111 Bankruptcy, 17, 18 California Legislature, Sidney Garfield and, 85 Sidney R. Garfield and, x Bar Mitzvah, for Sidney Garfield, 8 Canon of Ethics, 30 Total Health Care Project in, 107 Barrymore, Lionel, 34 Can Physicians Manage the Quality and Costs of American health policy, computers and, 92 Barton, Jane, 90 Health Care? (Smillie), 53

139 THE STORY OF DR. SIDNEY R. GARFIELD

Care Management Institute, xv Morris Collen and, 94, 96-99 “Delivery of Medical Care, The” (Garfield), 86, Care management programs, 102 Sidney Garfield and, 85-86 100-101, 120-131 Carroll, Mary, 46 in Total Health Care Project, 116) Demand, in health care systems, 126, 127-129 Center of Excellence for Culturally Competent Congress, multiphasic testing program and, 98 Denver Care, 76-77 Consolidated Builders, Grand Coulee Dam project Kaiser artillery plants in, 76 Chandler, Loren, on “medical socialism,” 30 and, 24-25 Kaiser Permanente Health Plan for, 124 Change, 119 Construction workers Depersonalization, fear of, 92 in health care delivery, 121-124 Sidney Garfield’s treatment of, 2-3 Desert Center, 28, 44 Charitable trust, Permanente Foundation as, 67, 68 venereal diseases among, 3 Garfield’s hospital set up near, 1-2, 5, 16 Checkups, in health care systems, 126-127 Consultation, in group medical practice, 15 health care economics at, 17-21 Chelsea, Massachusetts, Sidney Garfield’s parents “Consumer-directed health plans,” xii Desert Center Café, 5 in, 6-7 Continuing life record, 102 Design, modern hospital, 86-91. See also Hospital Chester, Alyce. See also Kaiser, Alyce Contra Costa County, 78 design Bess Kaiser treated by, 77 Contractors General Hospital, xi, 58 Design innovations, by Sidney Garfield, 44-45 marriage to Henry Kaiser, 78 founding and early history of, 1-5 De Silva, Joseph T., 74 Chester, Michael, 77 Grand Coulee Dam project and, 22-27, 31, 38 Diagnosis, in health care systems, 127 Chicago, Sidney Garfield’s 1944 AMA speech in, health care economics revolution at, 17-21 Diagnostic techniques, Kaiser Permanente 15-16, 51-52, 109-111 Control station, in Kaiser hospital design, research on, 114 China, medical care in ancient, 21 112-113 Dining rooms, in Kaiser hospitals, 89 Chinese workers, World War II health care Convalescent patients, Kaiser hospital design Disabilities, World War II health care program for program for, 39 and, 113 workers with, 39 Choice, Kaiser Permanente Health Plan and, 125 Conveyors, in Kaiser hospital design, 112 Disease care follow-up, in Total Health Care Chronic conditions/diseases Copayments, 55 Project, 104 patients with, 101, 102 Corporate medicine practice, 54 Disease management ventures, xiii, xiv public health and, 71-72 Corridors, in Kaiser hospitals, 87-88, 112 Distinguished Service Award, 107 Chronic high blood pressure, treating Bess Kaiser Cost-effectiveness District of Columbia AMA association, opposition for, 77 of Kaiser hospitals, 88-89 to Permanente Health Plan and, 58, 63-64. Civilian injuries, at Kaiser shipyards, 37 maximizing, 55 See also Washington, DC Cleveland, Kaiser Permanente Health Plan for, 124 Costs Division of General Internal Medicine (U Clinical information, 95, 102 of group practice, 32-33 Pittsburgh), 73-74 Clinical research, 114 of health care delivery, 124 Division of Research, 95 Clinics in health care systems, 130 Doctor-patient relationship outpatient, 56 soaring medical, 12 fear of depersonalization of, 92 for poor people, 130 Cost spreading, 110 in health care systems, 129 Clothing, Sidney Garfield and stylish, 8 County General. See Los Angeles County General in Total Health Care Project, 116 Cold War, opposition to Permanente Health Plan Hospital Doctors, patient relationship with, xi. See also and, 57 Crosson, Jay, ix Physicians Collen, Bobbie, 99 Cuba, 24 Dodds, Ned, 41 Collen, Morris F. “Morrie,” xvi, xvii, 40, 126 Culp, Bryan, xix, xx “Dream Hospital: It’s the Last Word in Modern Permanente Foundation and, 69-70, 72, 93, Cutting, Cecil C., 93 Design,” 80, 87 94-95, 96-99 in Alameda County complaint, 60, 63, 64 in Total Health Care Project, 104 Bess Kaiser’s high blood pressure and, 77 Colorado River Garfield-Peterson marriage and, 78 Earl Carroll Theatre, 34 Garfield’s hospitals near, 1, 17, 19 Henry Kaiser, Jr.’s multiple sclerosis and, 76 Early detection Grand Coulee Dam project on, 22-27, 28-33 postwar group medical plans and, 54 emphasis on, x Columbia River, 43 recruitment to Home Front medical health care in health care systems, 127 Committee on the Costs of Medical Care, xiii, 11-12 program, 40 public health and, 71-72 opposition to Permanente Health Plan and, 57 recruitment to Mason City Hospital, 30-32, 33, 40 Economic integration, of health care, xiii Communism, opposition to Permanente Health in Total Health Care Project, 104 Economics Plan and, 57 vision of, 94 group medical plans in postwar, 53-54 Competitive position, 119 Cutting, Millie Cunningham, 30, 31, 78 revolution in medical care, 17-21 Comprehensive medical care, 19 Economy Comprehensive services, prepayment for, xi-xii of group medical practice, 15 Computers. See also Information technology (IT Daniels, Mark, on Oakland hospital, 89-90 at Permanente Foundation, 55 in Automated Multiphasic Health Testing Death rates, 62. See also Fatality rates “Economy of shortages,” 55 program, 96-99 de Kruif, Paul, 35, 45, 52 Educational Proceedings for the Permanente at Kaiser hospitals, 91-92, 94, 95-99, 100, 101 Alameda County complaint and, 61-64 Hospitals, 114 in health care delivery, 101-102 Henry Kaiser, Jr.’s multiple sclerosis and, 76 Educational programs, 113-114 in health care industry, xv-xvii de Kruif, Rhea, Alameda County complaint and, Educational section, in Total Health Care in health care systems, 126, 127 61-64 Project, 116 for medical records, 71

140 Index

Electronic aids, 95 Freedom of choice, Kaiser Permanente Health Geriatric problems, 95. See also Aging Electronic patient information, 102 Plan and, 125 Giannini, A. P., in financing Permanente in Total Health Care Project, 105 Friedman, Mel, 116 Foundation Hospital, 41-42 Electronic teaching machines, 100 Full-time groups, 111 Gilford, Steve, xx Elizabeth, New Jersey, Sidney Garfield’s parents Fundamental research, 114 Gillette, Hazel, 31 in, 7 Gillette, Ray, 30, 31 Emergency room (ER) patients, multiphasic testing Gilliam, Harold, 73 program and, 99 Garfield, Bertha, 6-8, 9 Goals Employer-based prepayment, xi death of, 84 of Kaiser Permanente, 114 Employers, and health care for workers, 25 Garfield, Helen, 79. See also Peterson, Helen of Permanente Foundation, 68-69 Engineering, as possible career for Sidney Chester of Total Health Care Project, 103, 106 Garfield, 8-9. See also Safety engineering Garfield, Isaac, 1 “Godfather” movies, 81 England, government health care in, 52 career of, 6-7, 8, 9 Government Entrances, in Kaiser hospital design, 112 death of, 84 in American health care, 109 Entry mix, in health care systems, 125, 126, 127, 131 Garfield, Sally, 7 in health care systems, 127 Episodic crisis sick care, programmed total health Garfield, Sidney R..See also Sidney Garfield entries Kaiser Permanente and, 114 care versus, 100 address to Monterey conference, 91-92, 95, prepayment group plans and, 111 Equipment, in Kaiser hospitals, 87-88, 124 96, 115-116 Government health care Ethics Committee, Alameda County Medical address to TPMG Board of Directors, 117-119 multiphasic testing program and, 98 Association, opposition to Permanente Army enlistment of, 36, 37 opposition to Permanente Health Plan and, Health Plan from, 59-66, 79 birth of, ix-x 58, 63, 114 Examinations, regular, 71, 72 college education, internship, residency, and private health care versus, 51-52 Exercise programs, 101 early career of, 10-16 Grammar school, Sidney Garfield at, 8 Experts, in American health care, 109 death of, 104 Grand Coulee Dam project, xi, xiii, 117, 124 Expo 67, 95, 100 demotion of, 82-84, 85 Contractors General Hospital and, 22-27, 31, 38 early post-World War II work of, 50-56 health care delivery system for, 28-33, 42, 54, extended family of, 7 58-59, 71 Fabiola Hospital, 41 formation of Kaiser Permanente and, xix recruiting physicians for, 28-33, 40 Facilities. See also Adequate facilities Grand Coulee Dam project and, 22-27, 28-33 termination of, 34 in health care systems, 128 health care economics revolution and, 17-21 workers from, 36-37 for Kaiser Permanente Health Plan, 124 Henry Kaiser and, ix, xi-xii, 46, 75-84 Great Depression, Sidney Garfield during, 1-5, 10-16 Family planning, 101 historical archives of, xix-xx Greenlick, Merwyn “Mitch,” on Total Health Care Fatality rates, 70. See also Mortality rates Hollywood and, 34-35, 40 Project, 104-105 Faye, Alice, 28 on hospital architecture and design, 86-91 Group Health Association of America, 107 Fee-for-service medicine legacy of, ix-xviii, 46 Group Health Cooperative of Puget Sound, 70 decline of, 66, 101, 110 marriage to Helen Chester Peterson, 78 antitrust lawsuit brought by, 58 in health care systems, 125 as medical group employee, 65-66 Group practice, xii-xiv, xix prepayment versus, x medical license suspended, 60 advantages of, xiii, 15-16, 21 Fees, in health care systems, 125-126 Mojave Desert career of, 1-5 as feasible medical concept, 109-111 Field Hospital, 44 1944 speech to AMA in Chicago, 51-52, 109-111 in health care systems, 130 Films, 99-100 opposition to, 43-44, 57-66 introduction of, 12, 14-15, 46 Financing organization of Permanente Foundation and, Kaiser Permanente Health Plan and, 124 for Kaiser Permanente Health Plan, 124 67-74 at Mason City Hospital, 32-33 for Permanente Foundation, 67-74, 114 parents, birth, childhood, and education of, 6-9 opposition to, 30, 43, 57-58, 58-59, 66 First aid crews, 48 Permanente Health Plan union membership Permanente Foundation as, 68 First aid stations, 19 and, 70-71 post-World War II problems for, 53-55 Fishbein, Morris physical appearance of, 35 prepaid, xiv opposition to, 66 release from Army service, 37-38 private practice versus, xii-xiii opposition to Permanente Health Plan from, renaming of Kaiser Permanente and, 80-84 promotion of, x 57-58, 60 as surgeon and administrator, 40-41 in Total Health Care Project, 106 “Fleur de Lac estate,” 82 surgical suite designed by, 44-45 as transforming modern medicine, 50, 51-52, 86 Flint, Thomas, in Alameda County complaint, 59, 60 after Tahoe Conference, 85-92 “Groups without walls,” xiii Flow, in health care systems, 125-126, 127-129 telling the story of, xx Fogarty, John, 93, 98 Tenth Anniversary Report by, 56, 112-114 Fontana, California Total Health Care Project of, 102-107 Hamby, Rex, 31 Kaiser artillery plants in, 76 unselfishness of, 29 Hancock, Lambreth, Kaiser-Garfield partnership Kaiser hospital in, 45, 71 vision of, 92, 93-107 and, 82-83 Kaiser steelyard at, 36, 38, 46 during World War II, 34-45, 46 Han, Paul K. J., 73-74 Food and Drug Administration, multiphasic testing Garfield, Virginia Jackson “Ginnie,” 65 Hatch, Harold, 17-18, 19, 37 program and, 98 Garfield and Associates, 42. See also Sidney Hawaii, Kaiser Permanente Health Plan for, 124. For-profit medical groups, 65 Garfield and Associates See also Honolulu

141 THE STORY OF DR. SIDNEY R. GARFIELD

Health, in hospital design, 90-91, 93-94, 95, 100 Health Education Center, 95 In-person classes, 99-100 Health care, 62 HEDIS measures, xiv, xv In-person patient visits, in Total Health Care comprehensive, 19 Hendricks, Ricky, 63 Project, 105 as a division of medicine, 100 Henry J. Kaiser Family Foundation, 107 Insurance companies, 2-3 economic integration of, xiii Heritage Resources Department, Sidney Garfield indemnity plans of, 109 for Grand Coulee Dam project, 22-27 archives in, xix, xx Insurance reform, opposition to, 58-59, 114 during Great Depression, 11-16 Herlihy, Ed, 87 Insurers, underpayment by, xv inequities in, 25 High blood pressure, treating Bess Kaiser for, 77 Integrated health care delivery systems, 106-107 under Kaiser Permanente, xiii, xvii-xviii High-deductible plans, xi-xii International Longshoremen and Warehousemen at Kaiser shipyards, 37-45 “High-performance networks,” xiii, xiv Union (ILWU) personal liability for, xii Holding company, Permanente Foundation as, 68 multiphasic screening program for, 72-74 private versus government, 51-52 Hollywood, 28-29,34-35, 40, 81 Permanente Health Plan for, 56, 70-71 reducing demand for, 20-21 Home Front medical care program, 38-45, 46, 59. Interns, in Kaiser Permanente hospitals, 113 revolution in economics of, 17-21 See also Permanente Foundation Hospital Interregional planning conference, in Monterey, Sidney R. Garfield and, x opposition to, 43 115-116 Health care delivery, 100-101 staffing of, 40 computers in, 101-102 Home Front National Historical Park, 36, 39 triage system for, 101-102 Home Front war, 36, 37 Janisse, Tom, xx via Total Health Care Project, 102-107 Homewood, California, 63, 81 Japan, war against, 33, 35 Health care industry, information technology for, Honolulu, Kaiser hospital in, 90. See also Hawaii Johnson, Lady Bird, 100, 107 xv-xvii Hoover, Herbert, xiii Journal of the American Hospital Association, Health care professionals, recruitment of, 28-29, Hoover Dam, 25 86, 109 29-33 Hospital design, 75, 86-91, 112-113. See also Journal of the American Medical Association (JAMA) Health care service, defined, 127-128 Design entries opposition to Permanente Health Plan from, Health care system(s) in Total Health Care Project, 106 57-58, 60 at Mason City Hospital, 32-33 Hospital holding company, Permanente Foundation removal of Morris Fishbein from, 66 Permanente Foundation as, 67-74 as, 68 Journals, from Permanente Foundation, 69-70 solving problems with, 130-131 “Hospital of the Month,” Walnut Creek hospital as, 88 Judaism, Sidney Garfield and, 6, 8, 10 Total Health Care Project as, 106 Hospitals Health education, 101, 102 in health care delivery, 121-123 in Total Health Care Project, 102, 103-104 Kaiser Permanente Health Plan and, 124 Kabat, Herman, Henry Kaiser, Jr.’s multiple Health Education Center, 99-100 in The Permanente Medical Group, 117 sclerosis and, 76-77 Health education programs, 99-100 prepayment group plans and, 111 Kabat-Kaiser Research Institute, 76 Health evaluation, in health care systems, 130 Hotel-type service, in Kaiser hospital design, 113 Kaiser, Alyce, 78, 79, 117-118. See also Chester, Health exams, payment for, xv. See also Medical Huntley, Chet, 87 Alyce examinations as director of Walnut Creek operations, 81-92 Health hazard appraisal, in Total Health Care Kaiser, Becky, 24 Project, 103-104 Immunizations, 101 Kaiser, Edgar F., 21, 30, 32, 33, 36, 39, 43, 49, Health insurance Imperial Dam, Sidney Garfield’s hospital at, 19 52, 107, 124 in American health care, 109 Individualized health improvement programs, in Grand Coulee Dam project and, 22-23 national, 120 Total Health Care Project, 103-104 meeting with Sidney Garfield, 23-27 prepayment and, 18-19 Industrial accidents, 2-3 in opposition to Kaiser-Chester marriage, 78 Sidney Garfield and, 85 Industrial Indemnity Exchange, 17, 18, 19 Kaiser, Edgar F., Jr., 107 solving problems with, 120 Grand Coulee Dam project and, 22 Kaiser, Elizabeth “Bess,” 67, 68 Health maintenance, xi, 102 Industrial medical care, Sidney Garfield and, 45 chronic high blood pressure of, 77 Health management organizations (HMOs), “Industrial medicine,” xi, 25 death of, 78, 117 evaluation of, xv Industry, prepayment group plans and, 111 Henry Kaiser, Jr.’s multiple sclerosis and, Health plans, “consumer-directed,” xii Infant care, 101 76, 77 Health policy, computers and, 92 Information Kaiser, Henry J., ix, 19, 21, 22, 27, 30, 49, 52, 66, Health professionals, medical computers for, 97. clinical, 95, 102 107, 110, 117-118, 124 See also Doctors; Physicians; Nurses; in hospital design, 90-91 in financing Permanente Foundation Hospital, Supervisors medical computers and, 97 41-42 Health profiles, in health care systems, 127 in Total Health Care Project, 106 first meeting with Sidney Garfield, 33 Health promotion, xiv-xv Information technology (IT), xv-xvii. See also Garfield-Peterson marriage and, 78 Health savings accounts (HSAs), xii Computers; Medical informatics Henry Kaiser, Jr.’s multiple sclerosis and, 76-77 Health systems, evolution of, xvi-xvii. See also centrality of, x opposition to Permanente Health Plan and, Health care system(s) Initial health exams, payment for, xv. See also 59, 61-64 Health testing, in health care systems, 126-127, Medical examinations organization of Permanente Foundation and, 127-129 Injuries, at Kaiser shipyards, 37 67-74 Healthy people, in health care systems, 126, Innovation(s), 119 partnership with Sidney Garfield, xi-xii, xiii, 127-129, 131 in Kaiser hospitals, 88-89, 90-91 xvii, xix, xx

142 Index

renaming of Kaiser Permanente and, 80-84 Kaiser Shipyards, 36-37, 52, 65, 117 construction of, 13 Sidney Garfield and, ix, xi-xii, 46, 75-84 health care at, 37-39 Grand Coulee Dam project and, 29, 32, 71 vision of, 93 hospitals for, 45 mortality rates at, 62 World War II shipbuilding by, 46 postwar group medical plans and, 54, 55 organization of Permanente Foundation and, Kaiser, Henry J., Jr., 37 Kaiser steelyards, 36, 38 67, 69 death of, 77 Kaiser Wakes the Doctors (de Kruif), 52 Sidney Garfield’s internship at, 10-11 multiple sclerosis diagnosis for, 76-77 Kay, Raymond “Ray,” xii, 13-15, 16 Sidney Garfield’s residency at, 13-16 in opposition to Kaiser-Chester marriage, 78 organization of Permanente Foundation and, soaring health care costs and, 12-13 Kaiser, Sue, 23-24 67-68, 71, 74 Los Angeles Department of Water and Power, Kaiser automobile plant, 59-60 renaming of Kaiser Permanente and, 80-81 opposition to Permanente Health Plan Kaiser Company Keene, Clifford, in Alameda County complaint, and, 57-58 Grand Coulee Dam project and, 24-25 59-60 Lyndon Baines Johnson Foundation, 100, 107 in financing Permanente Foundation Hospital, 41 King County Medical Association, antitrust lawsuit Lyon, Elias, 94 organization of Permanente Foundation and, 67 against, 58 “Kaiser doctors,” 80, 81 Klein, Robert, on Total Health Care Project, 105, 106 Kaiser Family Foundation, 107 Knott, Margaret “Maggie,” 76 Management surveillance, in Total Health Care Kaiser Foundation Health Plan(s), xiii, xviii, 83-84 Kovno (Kaunas), Lithuania, Sidney Garfield’s Project, 103 goals of, 114 parents from, 6 Managers, and health care for workers, 25 medical computing and, 91-92 KP HealthConnect medical records, xv, xvii “Many Will Rise and Walk” (Kabat), 76 multiphasic testing program and, 98 Market, in health care systems, 126 Sidney Garfield with, 85, 87 Martin, Paul, 68 Total Health Care Project and, 115, 116 Laboratories Mason City, 25-26 Kaiser Foundation Hospital(s), 42, 83-84. See also in health care delivery, 121-123 Mason City Hospital, xiii Kaiser hospitals; Permanente Foundation in Kaiser Permanente hospitals, 113 Grand Coulee Dam project and, 24, 25-27, 28-33 Hospital in Total Health Care Project, 116 physicians’ salaries at, 29 Sidney Garfield with, 85, 87 Laboratory assistants, in screening, 72 recruiting physicians for, 29-33, 40 Kaiser Foundation Rehabilitation Center, 76-77 Labor-saving devices, in Kaiser hospitals, 87, 88 Mass production techniques, 63 Kaiser hospitals, expansion of, 90. See also Kaiser Labor unions, Permanente Health Plan for, 55-56. Mass screening, for ILWU members, 72-74 Foundation Hospital(s); Kaiser Permanente See also Unionized workers; Unions Mayhew, Clarence, 88 Hospital(s) Lafayette, California, 82 Mayo brothers, xii Kaiser Industries, 78 Garfield-Peterson residence at, 78, 79 Mayo Clinic, 87 opposition to Permanente Health Plan and, 59 Lake Merritt, Bess Kaiser treated at, 77 M.D. Computing journal, 101 Kaiser Medical Group, 80, 81 Lake Tahoe, 62-63, 81, 92. See also Tahoe entries Meals, in Kaiser hospitals, 89 Kaiser Permanente, xii, 58, 66, 71. See also Lawsuits, 4-5, 79 Medicaid, 126 Permanente entries antitrust, 58 solving problems with, 120 Clifford Keene and, 60 Leftists, opposition to Permanente Health Plan Medical advances, Permanente Foundation and, evolution of, 93-107 and, 57 69-70 foundations for, 86 Legislation, solving problems with, 131 Medical associations, Alameda County complaint Great Depression and, 14, 16 License to practice medicine, 60 and, 63-64 health care delivery by, 121, 124-126 Life Among the Doctors (de Kruif), 61 Medical care. See also Health care entries health care innovations of, x, xi-xvii, xvii-xviii Link, George, Kaiser-Garfield partnership and, inequities in, 25 health education programs sponsored by, 82-83, 85 prepayment group plans and, 111 99-100 Lithuania, Sidney Garfield’s parents from, 6 Medical Care Delivery System, 119 incorporation of, ix Loans, for Kaiser Permanente Health Plan, 124. Medical centers laying foundations for, 33, 46 See also Financing in health care systems, 130 Los Angeles County General Hospital and, 13, 16 Look magazine, Walnut Creek hospital in, 80 in prepayment group plans, 111 multiple sclerosis research and, 76-77 Loos, H. Clifford, opposition to Permanente Health Medical computing, at Kaiser hospitals, 91-92, 94. name change to, 75, 80-84 Plan and, 57-58 See also Computers; Information entries paramedical components of, 102 Los Angeles, 11, 82 Medical economics, Kaiser Permanente Health Sidney Garfield archives at, xix-xx competition for Sidney Garfield from, 2-3 Plan and, 124-125 Tenth Anniversary Report on, 56, 112-114 Garfield’s hospital set up between Phoenix Medical examinations, regular, 71, 72. See also Total Health Care Project of, 102-107 and, 1, 2 Automated multiphasic health testing; Kaiser Permanente Health Plan, 124-126. See Kaiser hospital in, 89-90, 112 Health exams; Multiphasic screening; also Permanente Health Plan Kaiser Permanente Hospital in, 87 Screening principles of, 124-125 Permanente Health Plan for, 56, 70-71, 74 Medical Examiners Board, in Alameda County versus traditional health plans, 125-126, recruiting physicians from, 28 complaint, 60 127-131 Sidney Garfield’s family in, 10 Medical facilities, transforming modern medicine Kaiser Permanente Hospital(s). See also Kaiser Sidney Garfield’s private practice in, 22, 23 via, 50, 110, 114. See also Adequate hospitals Walnut Creek hospital and, 79-80 facilities design of, 112-113 Los Angeles County General Hospital, xii, 1, 2, 16, Medical groups, Kaiser Permanente Health Plan educational and research programs of, 113-114 21, 28, 39, 44, 69 and, 124. See also Group entries

143 THE STORY OF DR. SIDNEY R. GARFIELD

Medical histories, in health care systems, 126-127. Multicultural workforce, World War II health care Oakland, California, 36, 38, 60, 68, 74, 76, 78, 82, 95 See also Records program for, 39 Automated Multiphasic Health Testing facility Medical home, xv Multimedia recordings, 99-100 in, 96 Medical informatics, 99 Multiphasic Health Testing facility, 93, 94, 96-99 Bess Kaiser treated in, 77 Medical information, in Total Health Care Project, Multiphasic screening. See also Screening expansion of Permanente hospital in, 77-78, 106. See also Records for ILWU members, 72-74 89-90 Medical journals, from Permanente Foundation, in Kaiser hospital design, 113 Health Education Center in, 99-100 69-70 Morris Collen and, 94, 96-99, 126 Home Front medical care program in, 39-40 Medical license, 60 public health and, 71-72 mass public health screening in, 72 Medical Methods Research Department, 95, 126 Multiple sclerosis, of Henry Kaiser, Jr., 76-77 Permanente Foundation Hospital in, 41-42, 43, multiphasic testing program and, 98 Multispecialty group practice, xii-xiv, xix 44, 45, 53, 67, 69, 72, 113 Medical professionals, postwar shortage of, 72 advantages of, 15-16, 21 Permanente Health Plan for, 55, 69 Medical records, xv, 71. See also Records introduction of, 12, 14-15, 46 Walnut Creek hospital and, 80, 82 Medical research at Mason City Hospital, 32-33 Oakland Airport, 79 by Morris Collen, 94, 96-99 opposition to, 57-58, 58-59, 66 Oakland Medical Center, 105 by Permanente Foundation, 69-70 Permanente Foundation as, 68 Oakland Tribune, 60 Medical services, fear of depersonalization of, 92 post-World War II problems for, 53-55 Obstetrical floor, in Kaiser hospital design, 113 “Medical socialism.” See Socialized medicine promotion of, x Olson, Charles, 31 Medical societies in Total Health Care Project, 106 Olson, Evelyn Sanger, 31 Alameda County complaint and, 64 as transforming modern medicine, 50, On-the-job injuries, 2-3 in health care systems, 129-130 51-52, 86 Open market, in health care systems, 126 Medical society plans, 109, 125 Multnomah County Medical Association, Sidney Ordway, Alonzo B. “A. B.,” 17-18, 19, 37, 41 Medicare, xv, 126 Garfield’s speech to, 15 in arranging meeting of Edgar Kaiser and solving problems with, 120 Multnomah Hotel, 23 Sidney Garfield, 22-23, 24 Medicine in Sidney Garfield’s release from Army service, health care as a division of, 100 37-38 health care delivery systems in, 127 National Advisory Commission on Health Oregon, 98 “industrial,” xi Manpower, 124 Kaiser Permanente Health Plan for, 124 preventive, xi National Association of Manufacturers, 69 Orinda, California, 63 specialization of, 110 National health insurance, 120, 130 Out-of-pocket personal liability, for health care, xii as taught at universities, xii-xiii NCQA, xiv, xv Outpatient clinics, 56 Medicine of the Future conference, 97 Neighborhood clinics, in health care systems, 130 Outreach neighborhood clinics, in health care Mental health counselors, in Total Health Care Neighbor, Justin Wallace “Wally,” xii, 13-14, 16, 20, systems, 130 Project, 102. See also Psychological 28-29, 30, 31, 78 counseling Neuberger, Maurine, 98 Michael Reese Hospital, Sidney Garfield’s New Deal, health care during, 11 Panorama City, California, Kaiser hospital in, 90 internship at, 10, 11 “New economy of medicine,” x Paper Age, information technology versus, xv-xvi Microbe Hunters, The (de Kruif), 52 New England Journal of Medicine (NEJM), 70 Paramedical components, 102 Mills Field airport, 61 on socialized medicine, 52-53 in health care systems, 129 Minnesota State Medical Association, xvi New York, 67 Paramedical personnel, 95 Model for National Health Care, A: A History of New York City, 107 Paraprofessionals, 101, 102 Kaiser Permanente (Hendricks), 63 Nonprofit health plans, 54, 65, 93-84 Parker Dam, Sidney Garfield’s hospital at, 19 Modern Hospital magazine, 45, 88, 90 Nonprofit operations, Kaiser Permanente Health Partnership, of Henry Kaiser and Sidney Garfield, Mojave Desert, 58-59, 71 Plan and, 124. See also Not-for-profit 75-84 Sidney Garfield’s career in, xi, 1-5, 42, 54 foundation Part-time work, in prepayment group plans, 111 Money, power of, 118-119. See also Cost entries; Northern Permanente Foundation, recruiting Patient records, in Kaiser hospitals, 87, 88. See Financing physicians for, 59 also Records Monitoring, in Total Health Care Project, 103 Northwest Permanente Medical Group, 97. See Patients Montefiore University Hospital, 74 also Group entries Automated Multiphasic Health Testing of, 96-99 Monterey, California, conference at, 91-92, 95, Not-for-profit foundation, need for, xix. See also with chronic conditions, 101, 102 96, 115-116 Nonprofit entries delivering health care to, 101-102 Montreal Expo 67, 95, 100 Nurse practitioners, in Total Health Care Project, 105 in health care systems, 125-126, 127-129, Moore, Richard, 31 Nurseries, in Kaiser hospital design, 113 129-131 Moore, Ysabel, 31 Nurses in Kaiser hospitals, 87-88, 112-113 Morgenthau, Henry, 45 in hospital design, 90 medical computers for, 97 Morris F. Collen Award of Excellence, 95 in Kaiser hospitals, 88, 113 relationship with doctors, xi Morris, Gene, Sidney Garfield’s partnership in Total Health Care Project, 102, 105 in Total Health Care Project, 115-116 with, 2-3 Nurses’ stations, in Kaiser hospital design, 112 Pearl Harbor, 33, 35, 37 Mortality rates, 62. See also Fatality rates Nursing and Utility Corridor, in Kaiser Pediatric screening, 95 Mother-baby bonding, 88-89 hospitals, 88 Peptic ulcer, mortality rates for, 62 “Mr. Pepys’ Diary” (Fishbein), 58 Nutritional information, 101 Perforated peptic ulcer, mortality rates for, 62

144 Index

Periodic health evaluation, in Total Health Care Permanente Metals Corporation, 36 Prepaid group practice, xiv Project, 103-104 Permanente Monterey Management Conference, Prepayment, xi-xii, 46 Perlman, David, 96 91-92, 95, 96, 115-116 for comprehensive services, xi-xii Permanente Creek, 68 Permanente School of Nursing, 113 employer-based, xi Permanente Foundation, 114. See also Kaiser Perry Building, mass public health screening as feasible medical concept, 109-111 Permanente entries at, 72-74 fee-for-service versus, x Alameda County complaint versus, 59-66, 79 Personalization, in Total Health Care Project, financial viability via, 42-43 creation of, 54 103-104 and health care costs, 12, 14-15 dismissal of Alameda County complaint Personal liability, for health care, xii in health care delivery, 121, 124 against, 64, 79 Personal physicians, in Total Health Care Project, in health care economics, 18-19, 20-21 economy practices at, 55 105 in health care systems, 125 founding and organization of, 67-74 Peterson, Helen Chester, marriage to Sidney Kaiser Permanente Health Plan and, 124 goals of, 68-69 Garfield, 78. See also Garfield, Helen at Mason City Hospital, 32-33 growing reputation of, 70 Pharmacists, multiphasic testing program and, opposition to, 30, 43, 57-58, 58-59, 64, 66 medical community support for, 64-65 98-99 in Permanente Foundation financing, 68, 71 medical research sponsored by, 69-70 Philanthropy, in Permanente Foundation post-World War II problems for, 53-54 membership growth of, 55-56 financing, 68 principle of, xi, xii Permanente Foundation Health Plan. See Phoenix, Garfield’s hospital set up between Los as transforming modern medicine, 50, 51-52 Permanente Health Plan Angeles and, 1, 2 Prescriptions, multiphasic testing program and, Permanente Foundation Hospital(s), 49, 74, Physicians 98-99 117. See also Home Front medical care in health care delivery, 121-124 Preventicare, 98 program; Permanente Hospital(s) in health care systems, 125, 126, 127-129, 129-130 Prevention, xiv-xv, xix, 102. See also Accident educational and research programs of, 113-114 in hospital design, 90, 112-113 prevention financing of, 41-42 at Kaiser Permanente, 83, 86 computers and, 92 in Oakland, 89-90, 95 Kaiser Permanente Health Plan and, 125 emphasis on, x mortality rates at, 62 medical computers for, 97 by group medical practice, 15, 46 opening of, 42-43 in The Permanente Medical Group, 117 and health care costs, 12 Permanente Health Plan union membership and, 71 in prepayment group plans, 111 in hospital design, 90-91 surgical suite for, 44-45, 86, 89 primary care, 102 at Mason City Hospital, 32-33 Permanente Foundation Medical Bulletin, 50, 94, remuneration of, 125-126 multiphasic testing program and, 98 112, 114 in screening, 72 opposition to, 30 clinical studies reported in, 70 in Total Health Care Project, 102-107 in public health, 72 launching of, 69 training of, 50-51 in Total Health Care Project, 106 Permanente Health Plan, 117, 124 Pickford, Mary, 11, 28 as transforming modern medicine, 50, 86 Alameda County complaint and, 64 Planning, in health care delivery, 121 Preventive [health] care, xiv, xv creation of, 54-55 Pneumococcal lobal pneumonia, mortality rates in health care systems, 129, 131 dismissal of Alameda County complaint for, 62 in Total Health Care Project, 106 against, 64, 79 Pneumonia, 70 Preventive maintenance service, 101, 102 introduction of, 47, 51-52 mortality rates for, 62, 70 Primary care physicians, 102 mass public health screening and, 73-74 Politics, in opposition to Permanente Health Plan, in Total Health Care Project, 103 medical community support for, 64-65 57-58, 63 Primary care teams, in Total Health Care Project, membership growth of, 55-56 “Pony express route,” 22 105 opposition to, 57-66 Poor people, in health care systems, 130 Private health care, government health care organization of, 69 Population-based care tools, in Total Health Care versus, 51-52 The Permanente Medical Group and, 65 Project, 105 Private practice union enrollment in, 70-71 Portland, Oregon, 36, 82, 97, 124 group practice versus, xii-xiii Permanente Hospital(s), 114. See also Grand Coulee Dam project and, 22-23 in prepayment group plans, 111 Permanente Foundation Hospital(s) Kaiser hospital in, 43, 90 Profits, medical services and, 63 in Alameda County complaint, 60-61 meeting with Edgar Kaiser in, 23-27 Programmed total health care, versus episodic architecture and design of, 75 Permanente Health Plan for, 56, 59, 70 crisis sick care, 100 Bess Kaiser treated by, 77 recruiting physicians from, 30 Prostitutes, venereal diseases from, 3 in Los Angeles, 56 shipyard in, 46, 47, 53 Psychological counseling, 101. See also Mental The Permanente Medical Group and, 65 Sidney Garfield’s speech in, 15 health counselors unionization of, 56 Portland Oregonian, opposition to Home Front Public entrances, in Kaiser hospital design, 112 Permanente Medical Group(s), xiii, 84. See also medical health care program by, 43 Public health, 71-72 The Permanente Medical Group (TPMG) Port workers. See International Longshoremen and in United States, 97-98 creation of, 56 Warehousemen Union (ILWU) Public relations history in Northern California, 16 Postwar conversion plans, 54-55. See also World at Kaiser Permanente, 77 Permanente Medicine, xii, xiii, xviii, 95 War II in Total Health Care Project, 116 foundation of, 67 Poverty medical care, 130 prevention at, xiv Power, 118-119

145 THE STORY OF DR. SIDNEY R. GARFIELD

Quality, of group medical practice, 15 Sacramento, 68 Permanente Medical Group formed from, 56 Quality health care Safety, at Kaiser shipyards, 37 post-World War II problems for, 53-55 delivering via prepayment plans, 109-111 Safety engineering, in health care economics, Sidney R. Garfield Chair in Health Sciences, 107 in health care systems, 130 20-21 Smillie, John G., xvi, 16, 53, 64, 71, 92, 93 at Kaiser Permanente, 114 San Bernardino Mountains, 28 Social insurance, health plans as, xii prepayment group plans and, 111 San Diego, Permanente Health Plan for, 70 Socialized medicine, 12, 15, 127 in United States, 120-131 San Francisco, 78, 88, 118, 124 group medical practice as, 15-16, 30 Alameda County complaint and, 61-63 opposition to, 43, 52-53 Kaiser [Permanente] hospital in, 56, 87, 89-90, Permanente Health Plan as, 57-58 Rational delivery system, 101-102 112 Society, promoting healthy, 102 Total Health Care Project as, 102-107 mass public health screening in, 72-74 Solidarity of purpose, power of, 118, 119 for United States health care, 120-131 organization of Permanente Foundation and, Southern California, 118, 119, 124 Reader’s Digest articles, 52, 61, 76 67-68 recruiting physicians from, 28 Records, 95, 102 Permanente Health Plan for, 70 Sidney Garfield’s real estate investment in, 34 in health care systems, 127 Walnut Creek hospital and, 79-80 Southern California Permanente Medical Group, in Kaiser hospitals, 87, 88 San Francisco Bay, 36 formation of, 74 in Total Health Care Project, 105, 116 San Francisco Chronicle, 73, 96 Special Committee on Aging, multiphasic testing Redistribution of medical care, prepayment group San Francisco County Hospital program and, 98 plans and, 111 mortality rates at, 62 Specialists, in health care delivery, 122-123 Referrals, in Total Health Care Project, 103, 104 recruiting physicians from, 30, 31, 40 Specialization, of medicine, 110 Regional Oral History Office, xx San Francisco Medical Center, multiphasic testing Spokane, Washington, 40 Regulation, in health care systems, 126, 127 program and, 98 Sprague, Charles, 49 Reno, Nevada, 78 San Francisco State College, 73 Spreading the costs, 110 Reports, on Total Health Care Project, 104-105 San Francisco State University, Permanente Staff Research Health Plan for, 55 in hospital design, 90 in health care delivery, 121-123 San Francisco Tuberculosis Association, 73 in Kaiser Permanente hospitals, 113 by Permanente Foundation, 69-70 San Jose, California, 116 Stand-alone disease management ventures, Research fellowships, 114 multiphasic screening program in, 72-74 xiii, xiv Research laboratories San Pedro, California, Permanente Health Plan Stanford University Medical School, 12 in health care delivery, 121-123 in, 70-71 recruiting physicians from, 30, 31 in Kaiser Permanente hospitals, 113 Santa Clara, California, Kaiser hospital in, 90 Starr, Kevin, 40 Research programs, 113-114 Satisfaction, in Total Health Care Project, 103 State medical associations/societies, 51, 110-111 Residents, in Kaiser Permanente hospitals, 113 Scholastic record, of Sidney Garfield, 8-9 opposition to Permanente Health Plan and, 58 Restraint of trade, opposition to Permanente School of Public Health (UC Berkeley), 73 Stewart, Alta, 31 Health Plan as, 58, 63-64 Science, expansion of medical, 12-13. See also Stewart, Frank, 31 Retail Clerks Union Local 770, Permanente Health Research entries Stewart, William, 98 Plan for, 56, 74 Scientific American, xvi, 86, 100-101, 102 St. Francis Hotel, 63, 69 “Revolutionary Medical Plan Comes to the Sidney Garfield’s article in, 120-131 Stockton Plan, 115 Waterfront, A” (Gilliam), 73 Screening. See also Automated multiphasic Sullivan, Louis, on hospital design, 86 Rhode Island, 98 health testing; Health exams; Multiphasic Sunset Boulevard, 34 Richmond, California, Kaiser hospital in, 43, 44, 45, 67 screening Supervisors Richmond Field Hospital, 48, 49 for ILWU members, 72-74 in health care systems, 129 Richmond First Aid Station, 49 Morris Collen and, 94, 96-99, 126 Kaiser hospital design and, 112-113 Richmond Shipyards, 36-39, 40, 45, 46, 47, public health and, 71-72 Surgeon General, multiphasic testing program 48, 52, 68, 69 Seattle, 30 and, 98 shutdown of, 53-54 antitrust lawsuit in, 58 Surgeons, training of, 50-51 Rights, medical care as, 130 Permanente Health Plan for, 70 Surgery, Sidney Garfield and, 40-41 Rooms, in Kaiser hospitals, 89 Seattle Medical Society, 59 Surgical suite, in Vancouver hospital, 44-45, 86, 89 Roosevelt, Eleanor, 45, 49 Service, 119 Surveillance, in Total Health Care Project, 103 Roosevelt, Franklin D. “FDR,” 11, 14, 34, 35, 45, 49 73rd Evacuation Hospital, Sidney Garfield in, 36, 38 Systems analysis, of health care systems, 125- Sidney Garfield released from Army service by, 37 Seward, Ernest, 97 126, 128 Rosie the Riveter/World War II Home Front Sherman Antitrust Act, opposition to Permanente National Historical Park, 36, 39, 46 Health Plan as violating, 58 Ross, Donald, opposition to Permanente Health Sick-care centers, 101 “Tahoe Agreement,” 84. See also Lake Tahoe Plan and, 57-58 Sickness, prepayment group plans and, 111 Tahoe Conference Ross-Loos Clinic, xi Sick patients renaming of Kaiser Permanente and, 81-84 Ross-Loos Medical Group, opposition to care for, 101, 102 Sidney Garfield after, 85-92 Permanente Health Plan and, 57-58 in health care systems, 125-126, 127-129 Teaching, in Kaiser Permanente hospitals, 113 Rowan, Charles, 14 Sidney Garfield and Associates, 40, 75. See also Team-based approach, in Total Health Care Runyen, Betty, 17, 18, 19, 20 Garfield and Associates Project, 103, 104, 105 Rutgers University, Sidney Garfield at, 9, 10 dissolution of, 65 Teamwork, in health care delivery, 121

146 Index

Technical assistants, in screening, 72 Universal-International newsreel, Walnut Creek Wellness, xi, 100, 101 Technology hospital in, 80, 87 in health care systems, 125-126, 127-129 expansion of medical, 12-13 Universities in hospital design, 90-91 in health care delivery, 121, 131 on group medicine, 110 in Total Health Care Project, 103, 106 10th Anniversary Report, 56, 112-114 medicine as taught at, xii-xiii Wellness training, 102 Thelen, Martin, Johnson and Bridges law firm, in University of California at Berkeley, xx, 73, 106 West Coast International Longshoremen and Permanente Foundation financing, 68 Permanente Health Plan for, 55 Warehousemen Union (ILWU) The Permanente Federation, 58 University of California at Los Angeles (UCLA), 71 membership in Permanente Health Plan, 70-71 The Permanente Medical Group (TPMG), 94, 105. University of California medical school, 70 multiphasic screening program for, 72-74 See also Permanente Medical Groups University of California Service, mortality rates Permanente Health Plan for, 56 address to Board of Directors of, 117-119 at, 62 Wetherill, Winnie, 31 Executive Committee of, 95 University of Iowa, Sidney Garfield at, 10, 11, 14 Wilbur, Ray Lyman, 12 formation of, 65, 66, 77 University of Michigan Hospital, 59 Wiley, Eugene, 31 information technology for, xvi University of Minnesota, 94 Williams, Greer, on Tahoe Conference, 84 Walnut Creek hospital and, 79-80 University of Pittsburgh Medical Center, 73-74 Willow Run, Michigan, 59-60 Therapeutic agents, Kaiser Permanente research University of Southern California (USC). See also Winchester, Sarah, 40 on, 114 USC entries “Winchester House,” 39-40 Theus, Gladys, 46 Sidney Garfield at, 10, 11, 13 Women. See also Rosie the Riveter/World War II Time magazine, 98 during World War II, 34, 36 Home Front National Historical Park Total health, in hospital design, 90-91, 93-94, US Army in Home Front medical health care program, 95, 100 Sidney Garfield in, 36, 37 39-40 Total Health Care Project, 102-107 Sidney Garfield released from, 37 World War II health care program for, 38-39 implementing, 115-116 USC School of Medicine, organization of Workers. See also Aqueduct construction workers; objectives of, 103, 106 Permanente Foundation and, 67. See also Construction workers; Unionized workers Tracy, Spencer, 38 University of Southern California (USC) during World War II, 35-36, 36-37, 38 Traditional health plans, Kaiser Permanente Health USC Surgery Service, 29 World War II health care program for, 38-45 Plan versus, 125-126, 127-131 U.S. Highway 60, Garfield’s hospital set up near, Workers’ compensation insurance, coverage of, 3 Training 1, 5 World War II, 117, 121, 122 in Kaiser Permanente hospitals, 113 U.S. Public Health Service American entry into, 35-36 of physicians, 50-51 computers and, 92, 96 Kaiser Permanente during, xi-xii, 46-49 Transparent Man, 95, 100 multiphasic testing program and, 98 Kaiser’s line of credit during, 42 Transparent Woman, 100 U.S. Secretary of Health, Education, and Welfare, largest civilian health care program of, 38-45, Trefethen, Eugene 107 46, 59 postwar group medical plans and, 54 Morris Collen and, 94 renaming of Kaiser Permanente and, 81 opposition to Permanente Health Plan after, Triage system, in health care delivery, 101-102 Vallejo, California, 76 57-66 Tufts University School of Medicine, 84 expansion of Permanente hospital in, 77-78 organization of Permanente Foundation after, Turnover, in Total Health Care Project, 116 Value-based benefit design, xii 67-74, 124 Vancouver, Washington Sidney Garfield during, 32, 33, 34-45, 46-49 Kaiser dam project near, 36, 38, 39 Underpayment, by insurers, xv Kaiser hospital in, 43-45, 86, 89 Unemployment, health care and, 11 Permanente Health Plan for, 56, 59, 124 Yale University, 88 Unionized workers, health care for, 25 shipyard in, 46, 48, 49, 53 “Young doctor Kildare,” 34 Unions. See also International Longshoremen and “Variations in Industrial Medical Service plans” Yuma, Arizona, Sidney Garfield’s hospital at, 19 Warehousemen Union (ILWU) (Garfield), 109-111 membership in Permanente Health Plan, 70-71 Venereal diseases, among construction workers, 3 multiphasic screening program for, 72-74 Visitors, in Kaiser hospitals, 87-88 Zeta Beta Tau fraternity, Sidney Garfield in, 10 opposition to Permanente Health Plan and, 57 Zoloth, Laurie, 11 Permanente Health Plan for, 55-56 United States. See also American entries; Walkways, in Kaiser hospitals, 87-88 Government entries; National entries; U.S. Wallace, Henry, 45 entries Wallin, Ira, 71 entry into World War II, 35-36 Walnut Creek Kaiser Foundation Hospital, 56, 77, health care delivery in, 120-131 79-80, 81-82, 118 largest private, prepaid medical care program design and construction of, 87-91 in, 50 Washington, Kaiser Permanente Health Plan public health debate in, 97-98 for, 124 United States Maritime Commission, Sidney Washington, DC, 37, 68, 76. See also District of Garfield and, 45 Columbia AMA association United States Supreme Court, opposition to Weinerman, Richard, 73, 74 Permanente Health Plan and, 58, 63-64 Weisenfeld, Irv, 69

147 THE STORY OF DR. SIDNEY R. GARFIELD

A Timeline of the Life of Sidney R. Garfield, M.D.

1906 – Sidney Roy Garfield is born in Elizabeth, New 1945 – Garfield states that “maintenance of health” Jersey. is the central mission of his program and at- ...... tributes his success to combining prepayment, 1928 – Garfield earns his M.D. from the University of group practice, prevention, and facilities “under Iowa Medical School and completes a one-year one roof.” With Kaiser, he opens the medical internship. care program to the public...... 1929 – Garfield begins first residency training in general 1948 – At the height of opposition from the medical surgery at Los Angeles County General Hospital. mainstream to Garfield’s prepaid group practice ...... model, he successfully defends himself against 1931 – Garfield begins a second, two-year residency numerous charges brought before the Alameda- program as Head Resident in Surgery at Los Contra Costa Medical Society to try to shut Angeles County General Hospital. down his medical care program...... 1933 – Garfield opens a small, 12-bed hospital near 1950 – Garfield’s medical care program expands to tens Desert Center, California, to serve workers build- of thousands of members when the West Coast ing the aqueduct bringing Colorado River water International Longshoremen’s and Warehouse- to Los Angeles. men’s Union joins, followed by 30,000 Retail ...... Clerks Union members in Los Angeles within 1934 – Garfield adds prepayment and accident preven- the year. tion to his practice and is able to build and staff ...... two additional hospitals for aqueduct workers. 1955 – The “Tahoe Agreement” resolves governance ...... disputes among Permanente Medical Groups and 1938 – Edgar Kaiser, son of industrialist Henry J. Kaiser, the Kaiser Foundation Health Plan and Hospitals, convinces an initially reluctant Garfield to create though Garfield loses his leadership role and be- a similar medical program for the workers build- comes vice president of facilities and planning. ing the Grand Coulee Dam in Washington...... 1960 – Garfield challenges Kaiser Permanente to find 1939 – Garfield opens the Grand Coulee plan to work- new methods of providing health care, rather ers’ families and adds group medical practice, than just sick care, by using emerging computer organizing all care “under one roof.” technology. He triggers a revolutionary research ...... program that develops prototypical electronic 1941 – With the U.S. entry into World War II, Henry medical records. J. Kaiser creates record-breaking shipbuilding ...... operations in Richmond, California, and on 1970 – Garfield publishes “The Delivery of Medical the Columbia River in Portland, Oregon, and Care,” the most important paper of his career, Vancouver, Washington, with steel produced in in Scientific American. It is a blueprint for the Fontana, California. modern Kaiser Permanente...... 1941 – Kaiser again calls on Garfield to create a medical 1984 – Sidney Garfield dies while working on his last care program. Within a year, he has built the larg- research project — “Total Health” — which col- est civilian medical care program on the World leagues complete in 1987. Its name is the basis War II Home Front. for the modern description Kaiser Permanente ...... uses for itself — a “Total Health” organization......

148 How one physician’s revolutionary vision paved the way from a 12-bed hospital in the Mojave Desert at the height of the Great Depression to what is today the nation’s largest, most successful THE STORY OF nonpro t health care organization — Kaiser Permanente. Like the architect he always wanted to be, physician Sidney R. Gar eld spent most of his life designing and building a model of a new kind of health care. Built on the foundations of group practice (as opposed to solo practice), prepayment (as opposed to fee-for-service), and prevention and health promotion (as opposed to sick care only), it was in many ways the opposite, mirror-image of the way health care was nanced and delivered in the rest of America. In partnership with Henry J. Kaiser, one of the great industrialists of the early 20th century,

Gar eld stood rm against waves of early opposition from mainstream medicine and went on DR. SIDNEY R. GA R to build one of the most acclaimed and successful health care organizations in America. This book tells the story of Dr. Sidney Gar eld’s long and eventful career in turning his desert dream into a thriving and enduring reality that continues to oer a practical model for the future of American health care.

Words from Permanente Medical Leaders

Thank you for the advance copy of your new Dr. Gar eld was a remarkable man and this book on Dr. Gar eld. I could not stop reading book does an excellent job of chronicling his it until I had nished it all. Congratulations on contributions. I am optimistic that as a result of FIELD a great book that will help new readers better his visionary leadership, Kaiser Permanente is understand and appreciate Gar eld's genius about to become the model for health care in and persistence. this nation. — Morris F. Collen, M.D., Emeritus Director, — Robert Pearl M.D., Executive Director and CEO, Division of Research, The Permanente Medical Group, The Permanente Medical Group, and President and CEO, Gar eld colleague and friend The Mid-Atlantic Permanente Medical Group DEBLEY

Cover image © St. John Moran Cover design by Lynette Leisure US $19.95

TOM DEBLEY

The Permanente Press IN COLLABORATION WITH Oakland, California • Portland, Oregon JON STEWART