Health Policy Advisory HEALTH PAC Center No. 55 November 1973 taiLta. mi

THE KAISER PLAN

on a variety of government policies, en­ ial: HMO's dorses HMO's in its April, 1973 report. When Forbes and Fortune magazines run Westinghouse is studying the possibility successive articles contending that health of starting one in Florida. Texas Instru­ maintenance organizations (HMO's) are ments is already involved in setting up "sensible surgery for swelling medical one, and Litton Industries wants to give costs," we know that big business is in­ "seed money" for a number of HMO's. terested. When the supermarket magazine Connecticut General Life Insurance Com­ Family Circle publishes a story entitled pany and the Equitable Life Assurance "Is There An HMO In Your Future?" we Society have made significant commit­ realize that the official word is spreading ments to HMO's. Connecticut General's to the American people. new subsidiary operates them in New Yet most Americans don't understand York, Arizona and Maryland and Equit­ the HMO concept. An HMO is a health able organized and recruited subscribers care organization which is intended to for the Lovelace-Bataan HMO in Albu­ provide comprehensive services to a vol­ querque. untarily enrolled membership at a pre­ One of the most successful HMO's is paid fixed fee. Usually an HMO is affili­ the Kaiser-Permanente medical care pro­ ated with one or several hospitals. It may gram, a prepaid group practice which has be funded privately, publicly or by a been operating in California for over 30 combination of both; it may be for-profit years. Kaiser's membership in California, or "non-profit." Doctors can practice full- Portland, Hawaii, Denver and Cleveland time or part-time within the HMO, and exceeds two and a half million. can be salaried or paid fee-for-service. Other HMO models have emerged that Only three years ago there were 30 are different from Kaiser. Most notable HMO's. Today there are over 60 with are the foundations for medical care, cre­ eight million subscribers. At least 46 in­ ated by private doctors (See BULLETIN, surance companies are participating in or February, 1973). A foundation, unlike have "exploratory interest" in operating Kaiser, is not a visible institution but 63 HMO's. Blue Cross hopes to open 280 simply a mechanism through which paper by the mid 1980's. and money flow. Care is provided in pri­ Big business is also joining the band­ vate doctors' offices and hospitals where wagon: the elite policy-forming organiza­ the doctors have admitting privileges. Pa­ tion, the Committee for Economic Devel­ tients pay insurance companies, insur­ opment representing most American busi­ ance companies pay the foundation, and ness leaders and with considerable clout the foundation pays the doctor or hospital CONTENTS services. The reason for this is the work­ ings of the profit motive. Whether for- profit or technically "non-profit," private 4 Kaiser corporations have always committed themselves to maximizing their income, reducing their expenditures, and using the surplus for expansion. The profit incentive leads private HMO's to limit services by hiring an inadequate number of physi­ cians and other personnel so that patients will be discouraged from seeking care. on a fee-for-service basis. In this way, expenses go down and sur­ Prepaid health plans (PHP's), particu­ plus goes up. larly growing out of California's Medicaid HMO's, then, take the profit incentive program, are another HMO innovation. of fee-for-service medicine and turn it on The state pays the PHP a fee for each its head. Whereas fee-for-service doctors Medicaid patient enrolled and the PHP and hospitals make more money by see­ provides care at its own clinics or at ing more patients, performing more op­ separate doctors' offices and hospitals erations and hospitalizing people longer, through contracts. HMO's increase their net income by doing The main success that HMO's can claim less. Either way the situation can be dele­ is cost reduction. Kaiser can provide a terious to people's health. package of services at lower cost than Besides the conflict between cost reduc­ identical services would cost in "main­ tion and availability of services, private stream" medicine. The way in which an HMO's oriented primarily toward their HMO reduces cost is by lowering the use surplus income are actually unable to cut of services by its members. Kaiser mem­ costs significantly over the long run. For bers, for example, spend half as many equivalent services, Kaiser costs less than days in the hospital as a similar popula­ Blue Cross/Blue Shield, but Kaiser's rate tion of Blue Cross /Blue Shield subscribers. of cost increase is just as great as, or And the amount of surgery performed by greater, than the national rate of increase. Kaiser compared to fee-for-service practice Thus HMO cost reduction is a one-shot af­ is distinctly lower. fair; if the entire health system switched In the case of hospitalization and sur­ next year from fee-for-service financing to gery, which most Americans are sub­ HMO financing, the costs of care might dip jected to in dangerous and costly excess, down, but would then inflate as rapidly as HMO's can perform a positive service. ever. Within a few years any cost reduc­ But HMO's will also tend to lower the tion would be virtually cancelled out. availability of services that are not pres­ Again the reason is profit. Each pro­ ently performed in excess. At Kaiser, am­ vider and supplier of service—whether the bulatory care is not easily accessible- construction company, the manufacturer large numbers of patients complain of of the EKG machine, or the doctor—will several week waits for appointments, of raise prices as fast as possible in order rushed impersonal treatment, and of be­ to make more money. ing unable to find and keep a personal If HMO's are no long-term answer to physician. cost rises, do they solve the other com­ Thus HMO cost reduction goes hand in ponents of our health crisis? Here the an­ hand with a general inaccessibility of swer is even simpler—they do not. Even

Published by the Health Policy Advisory Center, 17 Murray Street. New York, N. Y. 10007. Telephone (212) 267- 8890. The Health-PAC BULLETIN is published 8 times per year; January, February, March, April, May, Sept- tember, October and November. 3 special reports are issued during the year. Yearly subscriptions: $5 stu­ dents, $7 other individuals. $15 institutions. Second-class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Oliver Fein. Nancy Jervis, David Kotelchuck. Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake. Thomas Bodenheimer. Judy Carnoy. San Francisco office: 558 Capp Street. San Francisco, Cali­ fornia. 94110. Telephone (415) 282-3896- Associates: Robb Burlage. Susan Reverby, Morgantown. West Virginia; Constance Bloomfield, Desmond Callan, Kenneth Kimmerling. Marsha Love, New York City; Vicki Cooper. Chicago; Barbara Ehrenreich. John Ehrenreich. Long Island. © 1973.

2 within HMO's, care will be fragmented as "mainstream" medicine, acute illness will long as specialists so heavily outweigh always take precedence over preventive the number of general providers of care. care. HMO's can do nothing to attract doctors People who believe that HMO's should and other health personnel to rural and be publicly-controlled and service-ori­ ghetto areas. HMO's will not open their ented rather than privately-run and profit- doors to people unable to pay. And evi­ oriented have two courses of action. They dence suggests that even when lower in­ can try to set up local health plans pub­ come people are insured, they have a far licly controlled by the users and em­ harder time getting care from the HMO ployees. Community groups across the than does the middle class. country are planning or even actually es­ Finally comes the myth of health main­ tablishing their own HMO's or PHP's. But tenance—that it's cheaper for an HMO to the capital requirements needed to start, prevent disease than to cure it. In the and the enormous time and energy spent short run, that's just not true. Annual Pap on technical proposals, plans and con­ smears, breast exams, blood pressure tracts are almost prohibitive. It is the rare checks, glaucoma screening and other community that will put together a plan valuable early diagnostic procedures cost that it really controls without being in­ money and require more medical person­ debted to a lending institution or a group nel. The savings—in reduced numbers of of doctors. The alternative is a struggle seriously ill patients—come only many for areas of power in private HMO's—for years later (if then), far beyond the pro­ community positions on the board, for em­ jections of corporate accountants and ployee meetings in specific clinics and planners. Only with large federal grants hospital wards, and for public airing of has Kaiser offered multiphasic screening planning documents and financial trans­ exams to many of its subscribers, and actions. In either case, HMO's will in­ with cutbacks in the grants, Kaiser is re­ creasingly be foci of community and ducing the screening. In HMO's as within health worker action in the health system.

STATEMENT REQUIRED BY THE ACT OF AUGUST tion 4359 of this title shall mail such matter at the rates 12, 1970: SECTION 3685, TITLE 39, UNITED STATES provided under this subsection unless he files annually with CODE, SHOWING THE OWNERSHIP, MANAGE the Postal Service a written request for permission to mail MENT AND CIRCULATION OF THE HEALTH PAC matter at such rates." In accordance with the provisions BULLETIN. of this statute, I hereby request permission to mail the 1. Title of Publication: Health-PAC BULLETIN. publication named in Item 1 at the reduced postage rates 2. Date of filing: September 28. 1973. presently authorized by 39 U.S.C. 3626. Signed, Ronda 3. Frequency of issue: 8 times a year, January, Febru­ Kotelchuck, managing editor. ary, March, April, May, September, October, November. 10. For completion by nonprofit organizations authorized 4. Office of Publication: 17 Murray Street, New York, to mail at special rates (Section 132.122, Postal Manual). New York 10007. The purpose, function, and nonprofit status of this organi­ 5. General business oflice of publishers: 17 Murray zation and the exempt status for Federal income tax pur­ Street, New York, New York 10007. poses have not changed during fhe preceding 12 months. 6. Publisher: Health Policy Advisory Center, Inc.; Edi­ 11. Extent and nature of circulation: average number tor: Howard Levy, c/o Health-PAC, 17 Murray St., of copies each issue during preceding 12 months: total N. Y., N. Y. 10007; Managing Editor: Ronda Kotelchuck, number of copies printed (net press run, 4,000; paid cir­ c/o Health-PAC. 17 Murray St., N. Y., N. Y. 10007. culation: (1) sales through dealers and carriers, street 7. Owner: (If owned by a corporation, its name and ad­ vendors and counter sales: 0; (2) mail subscriptions: 2,200; dress must be stated and also immediately thereunder the total paid circulation: 2,220; free distribution by mail, names and addresses of stockholders owning or holding 1 carrier or other means: (1) samples, complimentary, and percent or more of total amount of stock. If not owned by other free copies: 292; (2) copies distributed to newsagents, a corporation, the names and addresses of the individual but not sold: 128; total distribution: 2,620; office use, owners must be given. If owned by a partnership or other left-over, unaccounted, spoiled after printing: 1,380; total: unincorporated firm, its name and address, as well as that 4,000. of each individual must be given.) Private, non-profit Actual number of copies of single issue published near­ membership corporation: Health Policy Advisory Center, 17 est to filing date: Total number of copies printed (net Murray Street, New York, N. Y. 10007. Members: Oliver press run): 4,500; total paid circulation: 4,500; sales Fein, David Kotelchuck, Ronda Kotelchuck, Louise Lander, through dealers and carriers, street vendors and counter Howard Levy, Nancy Jervis, Judy Carnoy, Tom Boden- sales: 0; mail subscriptions: 2,243; free distribution by heimer, Elinor Blake. mail, carriers or other means: (1) samples, complimentary 8. Known bondholders, mortgagees, and other security and other free copies: 183; (2) copies distributed to news holders owning or holding 1 percent or more of total agents, but not sold: 88; total distribution: 2,514: office amount of bonds, mortgages, and other securities: None. use, left-over, unaccounted, spoiled after printing, (held in 9. For optional completion by publishers mailing at the office for future orders): 1,986. Total: 4,000 regular rates (Section 132.121, Postal Service Manual) 39 I certify that the statements made by me above are U.S.C. 3626 provides in pertinent part: "No person who correct and complete, (signed) Ronda Kotelchuck, manag­ would have been entitled to mail matter under former sec- ing editor.

3 CORPORATE MEDICINE: THE KAISER HEALTH PLAN

"I want to see a thousand of these health unit for a battery of tests with a follow-up centers all over the country," declared doctor visit. Generally Kaiser covers many Henry J. Kaiser in 1950. Well, it would more medical services than most private warm Henry J's gravestone if he knew insurance, and leaves fewer deductibles that today his name is linked with the and other out-of-pocket payments for the most important health care reform in a patient. Another important and innovative troubled America. The Kaiser-Permanente feature at Kaiser is that doctors are paid medical care program operates through­ on a salaried rather than fee-for-service out most of California, up to Portland, out basis. to the Hawaiian Islands, into Denver and While Kaiser administrators and re­ east to Cleveland. searchers have written extensively about Kaiser-Permanente (K-P) has its propo­ Kaiser's positive achievements, a critical nents and its critics. K-P, which is group- study is needed to sort out the successes practice based, has stopped hospital over- from the failures and to address certain utilization and cut costs, supporters claim. guestions: Why is a large corporation like Critics counter that Kaiser provides "as­ Kaiser Industries, traditionally engaged sembly-line medicine" and, because it in construction, mining and aerospace, as­ cuts costs, care is mediocre. Many Cali­ sociated with a health plan? Is K-P really fornia subscribers think "Kaiser's not non-profit? Does it truly keep down the good, but it's the best around." costs of medical care? And how do its Kaiser certainly differs dramatically subscribers feel about the care they from traditional American medical care. receive? People buy insurance from the Kaiser Foundation Health Plan usually through Kaiser-Permanente's their union or place of employment. But the insurance is good only for care of­ Beginnings fered at K-P's own hospitals and clinics. Kaiser-Permanente sprouted in a field of When Kaiser members get sick, they cement: the colossal dam construction of call the nearest Kaiser facility and make the '30's. Hoover, Grand Coulee and Bon­ an appointment—with their personal phy­ neville dams were all built by Kaiser In­ sician if they have one, or freguently with dustries under government contracts. whatever specialist seems appropriate. Be­ In 1933, more than 5,000 Kaiser workers cause appointments are often hard to get, were cutting a canal to carry fresh water people needing immediate treatment can from the Colorado River's Hoover Dam to go to the drop-in-clinic or emergency Los Angeles. The project spread over 400 room. Those desiring a physical check-up sguare miles of desert, and injuries or are referred to the multiphasic screening sickness meant a 200-mile trip to Los

4 Angeles. Because of the distance, Kaiser the New Deal years, the air was filled built medical facilities in the nearby area. with federal and state proposals advo­ Henry Kaiser made an agreement with cating compulsory health insurance. This Sidney Garfield, an enterprising young movement was strongest in California doctor in Desert Center, California, to set where over a dozen progressive health up a prepaid medical service. Initially, bills were introduced during the late Kaiser paid the Desert Center Hospital '30's and '40's. and physicians a certain amount to cover A strong advocate of private enterprise, industrial injuries. Later, the workers Henry Kaiser in 1942 publicly warned, "If could voluntarily put in a nickel-a-day the doctors fear socialized medicine, if payroll deduction for general medical industry is anxious about the widening services. powers of the state, why not venture now, When Kaiser moved on to the Grand boldly, into the activity that will forestall Coulee Dam project, Garfield followed the superplanners in their schemes to di­ and continued his prepaid medical plan. rect medical services into the channels of For the first time, workers' families were distributive bounty?" (2) given full medical coverage, wives for In 1945, Henry Kaiser began a national seven cents a day and children for campaign for his new protoype of health twenty-five cents a week. insurance. He modestly proposed that the Federal Housing Agency guarantee 10 The Government Helps Out percent of local bank loans to non-profit At the onset of World War II the market groups that wanted to set up facilities for for dams slackened, and Henry Kaiser prepaid hospital care. The AMA called turned to shipbuilding. Again using gov­ Kaiser's program "socialized medicine." ernment contracts. Kaiser organized ship­ Kaiser countered that his prepaid medical yards in California, Oregon and Wash­ projects would operate as "business en­ ington, employed 200,000 people, and terprises motivated by the impelling force turned out fully 35 percent of all US mer­ of competition." (3) chant vessels made during World War II. But Kaiser did not need any legislation. As a result, Henry J was dubbed by His visions came true much faster than many as "Sir Launchalot." people expected. By 1955, K-P had over These shipyards were the basis for the 500,000 subscribers. first expansion of the Kaiser medical em­ pire. In order to keep his men healthy, Henry Kaiser built clinics at production Kaiser Is Big Business sites in Oakland, Richmond, Vancouver Whether Kaiser physicians or sub­ and at the Kaiser steel mill in Fontana, scribers like it or not, Kaiser-Permanente California. 'The financing of these clinics is part of the Kaiser Industries empire and was provided out of government contracts, is largely controlled by it. Kaiser Indus­ since their cost was accepted by the au­ tries consists of about 100 active com­ thorities as a bona fide operating expense. panies including Kaiser Aluminum and After the war the clinics and their equip- Chemical, Kaiser Steel, Kaiser Cement and ment were declared surplus war property. Gypsum, Kaiser Engineers and Kaiser The Kaiser Hospital Foundation was es­ Aerospace and Electronics. tablished by Kaiser and his wife, Bess, to Of the 17 persons on the board of di­ buy them at 1 percent of cost." (1). rectors of the Kaiser Foundation Health With the shipyards closed and the Plan and Hospitals, eight represent Kaiser Kaiser workforce plummeting, the health Industries. Most prominent is Henry plan was opened to the public and re­ Kaiser's son, Edgar, who is chairman of named the Kaiser-Permanente Plan. (The the board of both organizations. Kaiser name Permanente was Bess Kaiser's Industries' representation on K-P was even idea; Henry's first cement plant was lo­ stronger a few years ago, but as K-P be­ cated on the Permanente Creek.) Thus at came more successful and secure in its government expense, the K-P medical care West Coast position, it began responding plan was begun. to public pressures of the '60's and added non-Kaiser people with little power. As Henry Kaiser's Philosophy public relations man Dan Scannell quip­ Henry Kaiser's expansion into the ped, "Now we have a Black, a woman health field wasn't just "one of his crazy and an Oriental on the board." ideas," as many critics thought. During Many people ask why a successful

5 business would want to get involved with Washing Away Industry's Sins all the problems of health delivery. Dr. As California labor consultant Thomas Clifford Keene, president of the Hospitals Moore puts it, "the medical program is and the Plan, as well as a board member just so damn self-serving for Kaiser Indus­ of Kaiser Industries, sums it up in saying, tries. It washes away the sins of industry." "the unparalleled corporate interest in Health care is always a shining star to health and medical affairs . . . arose out pin on one's chest. When asked in inter­ of the needs and interests of the Kaiser views which of his ventures gives him the companies over the past 30 years." (4) most satisfaction, Edgar Kaiser always re­ We can only speculate what these needs sponds, "the Kaiser Medical Care Pro­ and interests are. gram."

Tomorrow the World

The Kaiser medical philosophy has not stopped at the American border, but is expanding throughout the world. Located on the 17th floor of the giant Ordway Building (part of the Kaiser Center) in downtown Oakland, a small staff is quietly spreading the word throughout the Third World under the guise of the Kaiser Foundation International (KFI)—funded by Kaiser Industries. KFI was originally organized in 1957 as a California non-profit corporation under the name of Kaiser Foundation of Hawaii. According to KFI's literature, its original purposes were to develop charitable, scientific, educational and hospital programs on a local basis. But in 1964, its emphasis had shifted to pro­ moting hospital and health care programs abroad. Reflecting its potential geo­ graphical scope, its name was changed to Kaiser Foundation International. Its board of directors include Dr. Clifford H. Keene, president, who is also director of both Kaiser Industries and the Health Plan and Hospitals, and vice-president Dr. James P. Hughes, also a director of Kaiser Industries. KFI is naturally following in the footsteps of its parent organization, the Kaiser Health Plan and Hospitals. Initially it was active only in those countries (Jamaica, Ghana, etc.) where one or another of the various Kaiser industrial and construction firms had business interests. The Foundation has organized and managed mostly occupational medical services for its employees—espe­ cially its foreign workers—located in remote areas. "In Ghana," according to Dr. Hughes, "it was quite clear that our medical mission at the outside would be to take care of the work injuries on the construction of the plant, so that the local government facilities would not be further burdened. . . . Our second consideration was that we had recruited a group of skilled people from around the world to go in and provide the technical know-how that the construction required. We knew that they would not go there, at least happily, without an adequate medical service. So there was no problem at all about identifying for whom we would be responsible at the outset, and to what extent." (Our italics.) (Health Care For Remote Areas, An International Conference, Kaiser Foundation International, 1972, page 21.) It's all very good for companies to provide health care facilities, but KFI is taking a giant step in developing its brand of medical delivery services for other countries. As a matter of fact, according to Hughes, "the majority of de­ veloping countries in which Kaiser Foundation International has worked to date have not been the site of Kaiser industrial or construction projects. . . . The mission that we in Kaiser Foundation International are charged with is to find places around the world where community health care can be improved by applying some of the principles developed in our domestic prepaid health plan." On Edgar's conscience may be the fact Kaiser and Taxes that Kaiser Steel is one of the big polluters In 1948, Henry Kaiser set up the Kaiser in southern California. Edgar Kaiser con­ Family Foundation which is entirely dis­ tributed sizeably to the campaign against tinct from the Kaiser Foundation Health California's recent ecology measure, Prop­ Plan. In doing so, Henry "seemed more osition 20. According to the Washington interested in providing a vehicle for tax Post (5), Kaiser Aluminum dumps large planning and estate management than in amounts of mercury-containing waste into execution of a charitable program," ac­ the Mississippi River in Louisiana. Con­ cording to a study by the usually staid troversy erupted in the San Francisco Bay Twentieth Century Fund (8). In fact, the Area over Kaiser Sand and Gravel's de­ Kaiser Family Foundation, the 27th largest facing of hilltops in Orinda. Other Kaiser foundation in the US, plays a key role in strip mining operations go on in Canada the control of Kaiser Industries by mem­ and Australia. bers of the Kaiser family. Another blot on Kaiser Industries' image The Kaiser Family Foundation is now is its rating in the top 100 Department of the single largest owner of Kaiser Indus­ Defense contractors' list. One of its tries stock, with a controlling share of wholly-owned subsidiaries, Kaiser Aero­ 32.7 percent. The next largest block of space and Electronics Corporation, pro­ stock, 8.5 percent, is owned by Edgar duces rocket motor nozzles and structural Kaiser, chairman of the board of Kaiser components for aircraft and missile pro­ Industries. Currently, Edgar is also a grams and electronic equipment such as trustee of the Family Foundation. The aircraft flight display systems. In 1972, Family Foundation's income from Kaiser Kaiser Aerospace and Electronics had a Industries' stock is tax-free. So Edgar can $9.7 million contract to build electronic make a large, taxable personal income equipment for the A-63 fighter-bomber from his own shares, and keep control which was used extensively over Viet­ over Kaiser Industries through the tax-free nam. Kaiser companies also have made Family Foundation shares. bombers, ammunition and built military Specifically, the Family Foundation pro­ bases (6). vides capital to the Kaiser Foundation Kaiser Aluminum and Chemical, in a Medical Care program to assist its ex­ new partnership with Aetna Life and pansion in California and into new re­ Casualty Company, is one of the coun­ gions of the US (9). The Foundation try's largest real estate and land develop­ donated $3.5 million to start a Kaiser- ment corporations. Directed by Edgar Permanente program in Cleveland, and $2 Kaiser, Kaiser-Aetna has developments in million for one in Denver. Seed money California, Hawaii, Arizona, Baltimore, for the Oregon and Hawaii ventures also Atlanta, Cincinnati, New Orleans and came from the Foundation. To insure that Texas. In 1970 it evicted over 100 poor na­ control of the Family Foundation never tive Hawaiian families at Kalama Valley. leaves Kaiser hands, all of the trustees of In a Wall Street Journal ad, Kaiser-Aetna the Family Foundation are past or present boasts, "If we're not already in your members of the boards of both Kaiser In­ neighborhood, perhaps we will be soon." dustries and Kaiser-Permanente. (Interest­ Nor is Kaiser above self-serving illegal ingly, for a while K-P directly owned $2 deals. The Wall Street Journal (7) reported million of Kaiser Industries stock, but sold that 36 officers of Kaiser Steel, including its shares in 1970.) The Family Foundation Edgar Kaiser, secretly bought 63,200 has received most of its stock from be­ shares in a Canadian coal mine. The quests in the wills of Kaiser family mem­ shares were supposed to be sold only to bers—in 1951 after the death of Bess Canadians. When the mine yielded prac­ Kaiser, in 1961 after the death of Henry's tically nothing, the Kaiser officers, with youngest son, and in 1967 following the inside information, sold their shares at a death of Henry himself. profit while making reassuring statements Kaiser Industries also receives a small, about the mine. The Securities and Ex­ but direct benefit from K-P's continuous change Commission investigated, and a hospital and clinic construction. Kaiser federal court issued an injunction against Engineers, a wholly-owned subsidiary of Kaiser's fraudulent activities. A Kaiser Kaiser Industries, designs most of the public affairs vice-president commented, hospitals and many of the materials used "Everything we've done is open and for construction are Kaiser's. One example above board." comes from Redwood City, California

7 where a building inspector explained, nurse explained, "The longer you're at "Of course Kaiser Industries builds their Kaiser the more you realize that you can hospitals, and they specify in their con­ get immediate care by demanding and tracts that it uses their own materials." shouting either on the phone or in the (10) clinics." Clearly, it is more economical for Kaiser to have a continuous stream of Kaiser's Growth new subscribers who don't know how the "Growth is a way of life for the Kaiser- system worlcs. Permanente Program," states the K-P 1969 annual report. Most subscribers don't even know that 4 percent of their premium How 'The Kaiser plus a minimum of 15 cents per member Health Plan Works per month is budgeted for expansion. Who Subscribes? K-P's eagerness to grow is reflected in Two and a half million people belong its over-subscription policy in some re­ to Kaiser. The Northern and Southern Cali­ gions. The southern California Panorama fornia regions each account for well over City Hospital provides a good example. a million, with the remaining 300,000 scat­ Three years ago, the Lockheed Corpora­ tered in Oregon, Hawaii, Ohio and Colo­ tion in Burbank was looking for a health rado. Yet, as Kaiser's own analysis plan for its 8,000 employees. Kaiser ini­ shows, its membership by no means re­ tially said that it wasn't eguipped to sembles the general population (12). handle that many more people for three Kaiser families had an average income years. But not wanting to lose the 3.3 mil­ of $11,309 in 1967 and 1968, while data lion dollars a year that 8,000 employees show southern California families aver­ would bring in, Kaiser changed its mind aging incomes of $10,421. Thus Kaiser when Lockheed began to look elsewhere. tends to enroll healthier people avoiding The Lockheed employees were not as­ the burden of those who need medical signed their own doctors until they were care the most—the chronically ill, elderly processed through a screening exam. But and poor. In the words of Kaiser's own appointments for the exam took up to six economists, "we are younger and rela­ months and even then, the members did tively under-represented in certain popu­ not receive a doctor unless they showed lation groupings, for example, the unem­ an abnormal test. The discrepancy in ployed, the indigent, the wealthy, the self- staffing for the new patient load was not employed, and people living in rural and fully rectified for three years. According other non-metropolitan areas." (14) It to one source, the entry of Lockheed em­ should be noted that Kaiser is no different ployees resulted in other Kaiser members than private insurance companies in skim­ getting lower guality services for their ming lower-risk people from the popula­ money, the new Lockheed workers getting tion; commercial insurers in southern partial benefits even though they paid full California, for example, have an even price, and hospital personnel working younger and healthier population than longer and harder hours with no increase Kaiser. in pay. In northern California 76 percent of Why does K-P expand? One important Kaiser members are in a healthy age reason was expressed by a K-P planner: group under 45 years, compared to 70 per­ "As long as we keep expanding, our pa­ cent of the general population (13). Only tient population won't get too old. If we 4.2 percent of Kaiser subscribers in north­ remain static, our average patient's age ern California are over 65, whereas 9 will get older and older and then we'll be percent of the general population is in in trouble economically. This way every this high risk age. Kaiser will not accept time we get a new union or a new factory, group enrollment that has more than 25 we get only the people who are working percent of its membership over 60 years. now and are in good health; not the re­ If it weren't for Medicare, Kaiser would tirees and the people who've had to quit have far fewer elderly people. because of a disabling disease." (11) This In northern California 87 percent of is good "business sense," because the members join K-P through a group, with older one gets the more medical services the employer generally paying all or part are required. Also at Kaiser, the longer of the monthly charges. Public employees one is a member, the easier it is to know —federal, state, local, including em­ and utilize the system. As one Kaiser ployees of school districts—constitute

8 K-P's Business K-P is a very successful business operation. Although it is legally a non-profit organization, its "excess income" is as high as many profit-making corpora­ tions. In 1971, K-P reported a tax-free net income of $12 million. Adjusting that figure for accelerated depreciation, and for corporate income taxes, Forfune claims that the organization's excess income would be 8.8 percent. This is about equal to that of the oil industry (9 percent) and only 0.3 percent below the average return for the Fortune 500 that year, according to Fortune. An indication of Kaiser's financial strength is its ability to borrow from the Bank of America at the prime rate. In January, 1973, Standard and Poor's awarded the Kaiser Plan an "A" bond rating—its first to a private non-profit corporation. Because of its legal non-profit status, K-P cannot pocket its profits. Much of its excess income is turned back into expansion and high administrative salaries and expenses. The total revenue of K-P in 1972 was $454 million. Of this amount, $363 mil­ lion came from members' dues; $44 million from supplemental charges (most of which comes from the pharmacy and the optical laboratories); $37 million from Medicare reimbursement, and $10 million from non-plan, industrial and non-member services. Expenses for 1972 were $441 million with $234 million going to physicians and their staff; $151 million going to hospital services—including the salaries of all hospital workers; $28 million for outpatient pharmacy and optical serv­ ices and almost $4 million for other benefits such as ambulance costs and reim­ bursements of members for out-of-area emergency expenditures; close to $7 million goes to Community Service programs, but almost all of the $7 million is reimbursed under federal research grants and contracts; and $13 million is used to administer the Health Plan.

more than 40 percent of Kaiser's total (after 10 months of membership). How­ membership. Non-group enrollment is 13 ever, different members have different percent of Kaiser's entire membership. plans, depending on the costs of the These persons enrolled on an individual monthly premiums. A more expensive basis or converted to individual member­ plan might include psychiatric service ship when they left an employer who had and long term care; a cheaper plan might Kaiser insurance. According to Kaiser charge the patient for certain services and spokesman Robert Zimmerman, the health limit the number of hospital days. plan will not accept high-risk individuals In southern California, for example, who are over 60 or have high blood pres­ Plan AA costs more per month and pro­ sure, diabetes or other chronic conditions. vides doctor visits, eye exams, and Benefits under individual enrollment are physical therapy free. Plan BC, with a more limited than those provided in lower monthly premium, charges $2 per groups and the premiums are higher. The doctor visit, eye exam and physical ther­ health plan may terminate the member­ apy treatment. Both AA and BC sub­ ship of individual members on 15 days scribers must pay "reasonable rates" for notice. Officials say this is seldom done. out-patient drugs. Plan M—for Medicare beneficiaries—is the most comprehensive; Comprehensive Benefits Kaiser receives a monthly payment from Kaiser's benefits are relatively compre­ the federal government plus an additional hensive compared to other health insur­ charge from the member for those services ance plans. Generally all subscribers re­ not covered by the government. ceive hospital services, out-patient care Currently the health plan does not with lab tests and X-rays, drugs, eye cover attempts at "suicide o± other inten­ exams, physical therapy, ambulance serv­ tionally self-inflicted injuries or illnesses ice, emergency care and maternity care (this would include overdosage of pills);

9 Structure of The Kaiser-Permanente medical care program is divided into four components: the Kaiser Foundation Health Plan, Kaiser Foundation Hospitals, Permanente Medical Groups and Permanente Services Incorporated. All four are decen­ tralized into six regions. The Kaiser Foundation Health Plan This "non-profit" corporation acts like an insurance company. The main dif­ ference between it and Blue Cross is that people insured by the Health Plan must (except in emergencies) use their insurance only at Kaiser hospitals with Permanente Medical Groups. So the Health Plan not only enrolls subscribers, it also arranges for their health services through contracts with the hospitals and medical groups. The Kaiser Foundation Hospitals The hospitals, also "non-profit", are run by the same board of directors as the Health Plan; in fact, these two components have almost amalgamated into one entity. Kaiser has over 20 hospitals, and the Health Plan contracts with non-Kaiser hospitals in Cleveland, Denver and San Diego where the program has relatively few subscribers. The Permanente Medical Groups (PMG's) The PMG's are groups of physicians, one in each of the six geographical regions. Legally they are profit-making organizations, though the profits go to the physicians themselves rather than to outside stockholders. The PMG's are separate from the Health Plan and Hospitals partly because of state laws that prohibit physicians from working under a lay employer, and partly in order to maintain the non-profit, tax-exempt status of the Health Plan and Hospitals. Structurally, the PMG's each have their own board of directors (sometimes called executive committee). The Health Plan pays the PMG's on a capitation basis, that is to say, the PMG receives a fixed amount of money per member per month. In operation

drug addiction; alcoholism; conditions be added, effective January 1, 1974. They covered by Workmen's Compensation; are: care for intentionally self-inflicted in­ military-service connected conditions; cus­ jury (this apparently is included because todial, domiciliary or convalescent care; at point of entry, it is difficult to diagnose cosmetic surgery; corrective appliances whether certain injuries or medical condi­ and artificial aids; extensive neuromuscu­ tions are self-inflicted); intensive care for lar rehabilitation and conditions resulting TB patients in specialized hospitals (there from a major disaster or epidemic." Also, is a low incidence of TB among Kaiser if a member is injured or taken ill while subscribers); emergency coverage up to temporarily more than 30 miles from a $3,000 occurring anywhere in the world Kaiser hospital, Kaiser will pay for treat­ (including 80 percent coverage up to ment in any hospital. Kaiser claims it will $50,000 and 365 days in the hospital). pay up to an aggregate maximum of $3,000 for emergency services and ambu­ Low-Income Care lance. There have been reported cases of By dabbling in small projects for low- emergencies, where Kaiser has not paid income people and publicizing these proj­ because it didn't deem certain injuries or ects far beyond their worth, Kaiser is try­ illnesses as emergencies. Subscribers suf­ ing to change its middle-class image. The fering emergencies within the 30 pile best-known effort is the Portland OEO pro­ zone must go to Kaiser or pay their own gram for 1,200 low-income families. Simi­ way. lar tiny programs were opened in south­ In northern California, new benefits will ern California and Hawaii. Kaiser is

10 P Medical Program this basically means that physicians are salaried. Salaries of Kaiser physicians are competitive with the medical marketplace. Beginning salaries range from $20,400 to $24,000 with fringe benefits up to an additional 25 percent. The average salary is around $40,000 plus substantial fringe benefits. According to PMG physicians, some specialists make $70,000 to $100,000. Each year besides cost-of-living increases, merit raises are doled out by department heads and the physicians-in-chief. For the first two years a doctor at Kaiser is an employee of the PMG, after which the physician is eligible to become a so-called "participant." After another year, the physician is eligible for partnership. The difference between a partner and a non-partner appears to be primarily financial. Once a partner, the doctor can share in all the profits of the group. Voting privileges are also acquired. Approximately two-thirds of Kaiser's more than 2,000 physicians are partners. Doctors' profits at Kaiser are variously termed the "contingency contractual payment," "divisible surplus." "bonus" or "incentive compensation." What this means is that after the budget for the entire medical care program (hospitals and PMG's) is prepared, an additional 5 percent is tacked on and made part of the final budget. Then, four or five times a year, any budgeted money left over is distributed equally between the PMG's and the Health Plan/Hospitals. The PMG money goes to the physician partners as a bonus, and usually runs from $7,000 to $9,000 in addition to their salaries. Permanente Services Incorporated (PSI) The profit-making Permanente Services corporations—one for each region— perform administrative and pharmacy services for the Hospitals and PMG's. PSI functions include accounting, payroll, employee relations, planning and construction management, and the operation of pharmacies for the hospitals and clinics. The profits of PSI go to its stockholders, the Kaiser Foundation Health Plan and Hospitals. PSI appears to be separate from the Health Plan and Hospitals for legal and tax reasons.

rightfully proud of the fact that the poor in 1972. This contract may not last. Under were cared for on an equal basis with a new conflict of interest law, no organiza­ regular Kaiser subscribers. Of course. tion can receive Medi-Cal contracts if any Kaiser received ample funds for its proj­ of its officers are state employees, legisla­ ects; in addition to paying the premiums, tors or commissioners. K-P may prefer ac­ OEO provides money for patient transpor­ cess to important government groups than tation, home care, staff training and other to serve low-income patients. social and outreach services. You can bet that these extras will disappear with OEO. Charity Begins At Home Without investing a penny of its own, A very small number of the medically Kaiser found through its OEO programs indigent—people without insurance. Medi­ that it could serve small numbers of poor care or Medicaid—get into Kaiser. On the people without a marked increase in costs average, according to a Health Plan rep­ per patient (15). This information is ex­ resentative, only 1 percent of any one tremely useful in deciding on further in­ hospital's inpatients are non-Plan sub­ tegration of low-income Medicaid patients scribers and have no insurance coverage. into Kaiser facilities and calculating reim­ They are financed by the individual facil­ bursement rates from Medicaid programs. ity's Medical Social Assistance Account. In an experiment with a prepaid Medi- In the past the percentage of charitable Cal (California's Medicaid program) con­ cases was much higher. The 1961 K-P tract, Kaiser's southern California Fontana Annual Report dedicated a page to chari­ facility signed up 1,200 Medi-Cal patients table care nobly stating, "The Com-

11 munity Service Program places special it is available, acceptable, compre­ emphasis on charitable care. . . . This hensive, continuous, and documented; charitable care program is designed to as­ and the extent to which adequate sist persons or families the social service therapy is based on an accurate di­ workers describe as 'medically indigent.' agnosis rather than symptomatology. They become 'medically indigent' in the I would add the criterion of dignity— face of heavy hospital or medical bills. the dignity accorded the recipient of . . . Any clergyman, community welfare services, and the dignity of style of agency representative, doctor or nurse the providers of services." (19) may refer these 'medically indigent' cases to Kaiser Foundation Hospitals." Availability Today Kaiser is far less generous with Almost everyone agrees that the US community services and rarely talks suffers from a shortage of doctors. But no about the individual medically indigent. one is sure just what the proper ratio of The community service funds allotted for physicians to patients should be for op­ "charity, research and education" are timal care. Kaiser views one physician largely funneled to physicians for indi­ per 1,000 members as the ideal, but does vidual research projects. This arrange­ not achieve its goal. In fact, Kaiser's phy- ment enables Kaiser to create a "uni­ sician-to-members ratio is lower than the versity atmosphere" for many of the "aca­ physician /patient population ratio of the demically inclined" doctors. As one San states in which Kaiser is located. The ratio Francisco doctor said, "research money of para-medical personnel to patients is is our sanity money. It gives us a half also lower at Kaiser, which employs an day or so to be away from patient care." estimated two persons per patient com­ pared with 2.8 nationally in "short-term hospitals." Quality of Care The most important aspects of medical Doctors per 100.000 Population—1969 (20) care are most difficult to measure. Only a Percent State Ratio K-P Ratio Difference few studies of Kaiser's quality of care have been done. Most useful are (1) a Northern 1972 study by Milton Roemer and others California 161 102 —36 Southern on comparative utilization rates, costs, at­ California 161 90 —43 titudes of patients, and quality of care Hawaii 133 83 —38 under three major types of health insur­ Oregon 128 67 —49 ance plans (Blue Cross/Blue Shield, pri­ Understaffing causes limited access for vate insurance company and Kaiser) (16), Kaiser subscribers. The usual complaint (2) an examination by Nolan, Schwartz among Kaiser subscribers is waiting on and Simonian of social class differences the phone to make an appointment, wait­ in the utilization of pediatric services at ing until an appointment is available, and the Oakland Kaiser clinic (17), and (3) waiting at drop-in and emergency clinics. the California Council for Health Plan Thirty percent of the CCHPA/MCHR re­ Alternatives (a union-sponsored organiza­ spondents wait over one month for an ap­ tion) and the Medical Committee for Hu­ pointment, and 27 percent wait from one man Rights 1973 mail questionnaire study to two hours to see a doctor at a drop-in of consumer satisfaction among 10,000 clinic. members of the Northern California Car­ Another problem facing many sub­ penters Union who subscribed to the scribers is that they live too far from the Kaiser Plan. (Because only 24 percent re­ nearest Kaiser facility. Among patients plied to the questionnaire (18), this study sampled at the Oakland pediatric drop-in must be viewed only as an indication of clinic, Nolan et al found 22 percent of pa­ consumer feelings.) tients making daytime visits and 53 per­ The findings of these studies will be dis­ cent of those making evening visits had cussed below in analyzing whether K-P a transportation problem (21). meets its own standards for quality care. Lack of access causes many subscribers Dr. Clifford Keene, as President of the to seek, and pay extra, for care outside Kaiser Foundation Health Plan and Hos­ Kaiser's facilities. 55 percent of those who pitals, has stated, answered the CCHPA/MCHR question­ "the criteria for judging quality in naire have used non-Kaiser medical serv­ medical care are the degree to which ices since joining K-P. 78 percent of these

12 people must pay for these outside services. Kaiser Plays The Roemer and his colleagues found that 12 percent of the services used by sub­ Numbers Game scribers in a 12-month period took place outside the Kaiser facilities. However, Kaiser's philosophy is one of effi­ there is no report on the number of sub­ ciency and cost-savings, and all per­ scribers involved. Certainly far more than sonnel are guided by it. Physicians 12 percent of the subscribers used these and clerks alike are pressured to per­ outside services. form to their limits; patients and The Kaiser Plan has its own statistics workers suffer as a result. which show even higher outside utiliza­ The telephone appointment proce­ tion. A K-P consumer satisfaction study dure is the crucial entry point into prepared by the Field Research Com­ the Kaiser system. All calls for ap­ pany found that 44 percent of a southern pointments are handled at a circular California sample replied affirmatively central appointment desk around that non-Kaiser physicians and non-Kaiser which sit a number of clerks. In the medical services had been used (22). center of the desk is a huge elec­ Kaiser officials discount this figure, stating trically controlled lazy-Susan filled that the survey did not ask whether the with all the physicians' individual services were referrals by Kaiser physi­ schedules so that each clerk can cians or whether these outside visits were handle any appointment for any pa­ covered by another health insurance plan tient to any physician. carried by the ether spouse. Kaiser's ex­ This all appears rather efficient. So planations are not convincing. The statis­ why do subscribers chronically com­ tics of outside use are relatively high and plain about long telephone waits of if a majority of them are due to referrals, up to an hour? The answer lies in then Kaiser is actually admitting that its Kaiser's "numbers game." services are inadequate. Furthermore, the In northern California, Kaiser's ad­ CCHPA study just cited above contradicts ministration has decided that each Kaiser's statement that members who use appointment clerk should be able to outside care are covered by other insur­ handle 25 calls an hour or an aver­ ance plans. age of five and a half to six physi­ When broken down by income, cians' calls. The clerks find this im­ Roemer's study showed that families earn­ possible to do. Doing their best, each ing under $11,000 seek more out-of-plan clerk handles about 150 calls a day. care than do families earning over that The clerks not only care for the pa­ amount, especially for maternity care. The tients' needs, but also shuffle calls to researchers suggest that lower income other departments. It is almost as if families may go out of Kaiser more often Kaiser deliberately wishes to make "because of some dissatisfactions or . . . access difficult. because they have not learned to 'work If the appointment procedure is the system' efficiently . . ." (23). sometimes a problem for patients, it It is difficult for any Kaiser subscriber to is also no joy for the appointment "work the system," but the general prob­ desk clerks. The supervisors of the lems of Kaiser come down hardest on peo­ appointment clerks, who realize that ple who have previously never been given the administration's goals are un­ the opportunity to navigate the health realistic, attempt to do their best. system. Kaiser's out-patient services are Each supervisor has a panel with organized with a white, middle-class bias. automatic counters and red lights Blue collar families utilize K-P services which flash on and off. The panel considerably less than do white collar shows how many calls have been families. Roemer showed that in a three taken every hour by each worker, month period, members of blue collar how many have been lost ("lost" families made only 662 doctor visits per calls are patients who hang up in 1,000 subscribers, but for white collar fam­ dismay), and how many are wait­ ilies the rate is 954 per 1,000 (24). ing at any particular moment. Utilization also differs considerably be­ tween whites and non-whites. Nolan re­ ports that "more than half the visits made

13 by white children were to the appoint­ ly, these clinics (and especially night ment clinics, but only one-third of the clinics) are staffed by moonlighting doc­ visits made by Negro . . . children were tors. to the appointment clinics. . . . Slightly Drop-in clinics serve as pressure valves more white patients came for health su­ on an understaffed, overworked system. pervision (school examinations) than for Without them Kaiser would have to hire acute conditions . . . among Negroes, for more full-time physicians and ancillary every preventive visit there were two for staff; drop-in physicians are frequently acute conditions." (25) part-time employees, not partners in the group practices. Acceptability One reason care at Kaiser is discontin­ Kaiser members like the prepayment uous is because specialty care is empha­ method of financing health care more sized, and is the core of the Kaiser design. than commercial plan holders like the fee- Only half of Kaiser's physicians are clas­ for-service system. But prepayment does sifiable as primary care physicians (gen­ not necessarily result in equal use of eral practitioners, internists, pediatri­ services by families or in equal sharing cians). The others are specialists or super- of costs. Non-utilization is actually an in­ specialists to whom patients are referred direct way of subsidizing the care re­ for illnesses which often could be treated ceived by the users of services. If there is by a primary care physician. a greater degree of non-utilization, as the Although many Kaiser members are Nolan and Roemer studies show, by lower victims of discontinuous care, Black pa­ income groups enrolled at Kaiser then tients fall overwhelmingly into this cate­ they are subsidizing the upper income gory. Nolan found that 48 percent of all groups who use the services more ex­ white pediatric patients visited the drop- tensively (26). in clinic, while 67 percent of all Black pa­ Attitudes toward medical care received tients received care there. Furthermore, 18 at Kaiser are less positive than attitudes percent fewer Black patients have a regu­ towards Kaiser's financing. K-P's own lar pediatrician than do white patients study, conducted by the Field Research (29). The CCHPA/MCHR study suggests Company, comes up with some startling that an even larger proportion of the total figures: "In both past and present sur­ Kaiser population is without a family phy­ veys," according to Greer Williams, "only sician. That study found 51 percent of re­ half of the members interviewed were sat­ spondents without a personal physician, isfied with procedures in K-P clinics, such of whom 71 percent expressed a desire to as getting appointments, promptness of have one. service, and so on." (27) What are Kaiser physicians' reactions Comprehensiveness to the lack of continuity? An intra-hospital Kaiser's benefits and coverage are com­ critique at the Santa Clara facility in­ prehensive when compared with other in­ cludes physicians' complaints of fraction­ surance plans, although dental care is not ated care due to overuse of the specialty covered and psychiatric services are clinics and poor screening techniques. limited. Kaiser covers a greater proportion They added that patients are scheduled of medical care costs than do other plans, to see a different doctor at each visit, even but the coverage is by no means totally for routine appointment follow-up. More­ comprehensive. Studies show that Kaiser over, they claimed, scheduling did not pays between 43 and 76 percent of total leave them enough time to see their pa­ medical care costs (28). tients adequately. Some physicians dis­ courage "difficult" patients from returning Continuity of Care or "punt" them from one doctor to another. Kaiser operates a dual ambulatory sys­ A major issue the physicians continue tem of care: a patient can take the ap­ to wrestle with is the emphasis of Kaiser pointment route or the drop-in route. The management on quantity rather than drop-in clinic is not integrated into the quality of care. As one physician explain­ rest of the system. Patients go there pri­ ed, "The system bases many things on marily because they don't know how to numbers without qualifying these num­ use the appointment system or because bers. The problem is pressure from the ad­ they don't feel they can wait the days, ministration which engenders a crazy weeks, or, for some specialties, even paranoid way about numbers." months to get an appointment. Frequent­ Every month a data sheet with the

14 count of patients seen in each department are made not just by the board of di­ and facility in the Northern California re­ rectors but by the board and the full gion is distributed to physicians-in-chief membership." (31) Interviews with physi­ and department heads. Some doctors cians in the Northern California region have been told by their department heads about the decision-making process reveal they were not seeing enough patients and a very different picture. shouldn't take educational leaves. One Kaiser doctor characterized the ex­ Some doctors feel their schedules are so ecutive committee as "an autocracy which rushed and inflexible as to preclude de­ makes decisions in the guise of 'quality livering adequate, humane care. The of care.'" Similarly a second physician schedules are also nerve-wracking to called them "self-serving, power hungry many physicians, and, as one doctor put men with coteries of syncophants who are it, "they have an ultimately eroding ef­ building personal empires." And a third fect on a physician's sense of responsi­ Kaiser doctor described them as "an oli­ bility for the patient." garchy ruled with an iron fist that makes decisions by fiat." Every day in one Kaiser physician's practice, a scheduling Democracy at Kaiser situation would arise in which "decisions Membership Participation were coming down from the top that in­ As far back as 1957, Henry Kaiser sum­ terfered with how care was delivered." med up K-P policy stating, "You don't (32) ask your corner grocer to share his owner­ Within the last two years, with the attri­ ship with people who buy at the store." tion rate increasing significantly, the phy­ Sixteen years later, K-P's attitude on mem­ sicians whose "opinions were neither bership participation remains the same. sought nor listened to" were so dissatisfied There are no member representatives or that members of the executive committee representatives of subscriber groups on were forced to tour the hospitals and the national board of directors. In the late tokenly restructure their committee. 1960's the unions attempted to get on the Today the committee's board, although board; Kaiser flatly refused them. it has changed from its original composi­ Thomas Moore, former executive di­ tion of self-appointed lifetime members, rector of the California Council on Health is still not elected by or accountable to Plan Alternatives, testified in 1971 before the full membership of the group. Now the the Senate Subcommittee on Health, that, committee consists of at least three old- after two years of complaining about timers whose power positions are un- Kaiser's inadequate patient grievance shakeable, plus the physician-in-chief procedures, K-P finally proposed some from each hospital, and one representa­ changes. Kaiser agreed to set up a griev­ tive from each clinic who is elected every ance committee "as long as every patient two years by the partners of that facility. bringing a grievance deposited $150 to Only those representatives from groups cover the cost of arbitration. . . ." "To us," of 25 doctors or more who have their own explained Moore, "it is absurd to put such hospital are allowed to vote. (The physi­ a heavy burden on a man who is making cians at the Sunnyvale Clinic and the a complaint so that he can't afford to South San Francisco Clinic, for example, make it." (30) are not voting members.) The company clique is still there; the physicians-in-chief Physician Participation are appointed by the executive committee and elected representatives are always K-P always emphasizes the democratic outnumbered. nature of the medical groups (See Box, Page 10 ) and their autonomy from the health plan. Kaiser considers it a "funda­ Worker Participation mental principle that the physicians must If things are difficult for doctors, one be involved in responsibility for adminis­ can imagine the situation of hospital trative and operational decisions that af­ workers. Like all hospitals, Kaiser workers fect the quality of care they provide." are not involved in any decision-making. Structurally the medical groups each The bulk of the workers at Northern Cali­ have their own executive committee. fornia Kaiser, including LVN's (LPN's), Kaiser states it in its literature that "there pharmacists, technicians, dishwashers, is constant input from the partners, both housekeepers, etc., are members of Local formal and informal. . . . Key decisions 250 of the AFL-CIO, the Hospital and In-

15 stitutional Workers' Union. one union representative, are on-the-job This fall Local 250 is negotiating a new training, career mobility, and lighter work contract with K-P. There are three areas loads. It should come as no surprise that that the union considers important: The the union considers this last issue to be first is wages. The union wants salary in­ the most difficult to negotiate with Kaiser. creases that will cover Bay Area cost-of- living increases. The second is health Utilization and Costs benefits. Kaiser gives its own workers Many people praise and promote Kaiser Plan D coverage, which is not the most for relative economies of costs and utiliza­ comprehensive. The union wants Plan SS, tion of hospital services. Studies generally a better package. The third concern is support the contention that economies ex­ that of working conditions. Some of the ist at Kaiser although the data are not specific working conditions the union entirely consistent. would like to see included, according to Four comparative studies are relevant

Who's Who on the Board

Edgar Kaiser—Chairman. Director of all Kaiser companies and subsidiaries. Clifford H. Keene, M.D.—Board of Directors, Kaiser Industries. E. E. Trefethan, Jr.—Officer on many Kaiser companies and President of Henry J. Kaiser Family Foundation. James A. Vohs—Employed by various Kaiser affiliated organizations; mem­ ber of the Secretary of Health, Education and Welfare's Task Force on Med­ icaid and Related Programs, 1968-70. Mary I. Bunting, M.D.—Ex-President of Radcliffe College; Commissioner with Atomic Energy Commission. Robert J. Glazer, M.D.—President of Kaiser Family Foundation; ex-Vice Presi­ dent of Commonwealth Fund; ex-Dean of School of Medicine, Stanford University. Arthur J. Goldberg—General Counsel for AFL-CIO and United Steelworkers of America; ex-Secretary, U.S. Department of Labor; ex-Associate Justice of U.S. Supreme Court. William Grant—Colorado National Bank; Chairman Democratic State Central Committee, 1965-69; ex-President of Metropolitan TV Company; ex-Chair­ man of the Board, Sangre de Cristo Broadcasting Company, Denver. William Hewlett—Chief Executive Officer and Director of Hewlett-Packard Corporation; Director, Chase Manhattan Bank and the Overseas Develop­ ment Corp.; Trustee of the Rand Corporation; Member of the President's General Advisory Committee on Foreign Assistance, 1965-68; Trustee, Stan­ ford University. Roy E. Hughes—Board of Directors of many Kaiser Industries Corporations. Henry M. Kaiser—Edgar's brother; Kaiser Glass and Fiber Corporation. George E. Link—Director of Texada Mines, Ltd., Minerva Bayovar, S.A., Kaiser Industries and Willys Motor, Inc. William Marks—Board of Directors of many Kaiser companies. Quigg Newton—President, Commonwealth Fund; Mayor, City and County of Denver, 1947-55; with Ford Foundation, 1955-56; President of University of Colorado, 1956-63; National Advisory Mental Health Council, National Insti­ tutes of Health, 1964-68. Mitchell W. Spellman. M.D.—Dean of the Charles R. Drew Postgraduate Med­ ical School. Arthur Weissman—Economist for Kaiser Health Plan. Ralph T. Yamaguchi—Assistant Public Prosecutor, City and County of Hono­ lulu. 1937-39; Special Deputy Attorney General of Hawaii, 1938-39; Director, Hawaiian Telephone Company.

16 to this discussion: (1) Roemer, et al., Although Kaiser is generally cheaper Health Insurance Effects, 1972 (33); (2) The than other health insurance plans, it cer­ Federal Employees Health Benefits Pro­ tainly is not the answer to inflation. gram, 1971 (34); (3) The Report of the Med­ Kaiser's costs have inflated faster than the ical and Hospital Advisory Council to the national average (the Consumer Price Board of Administration of the California Index for Medical Care or "CPI"). For the State Employees' Retirement System (35); ten year period 1960-70, the average med­ and (4) Family Medical Care Under Three ical care costs at Kaiser (premium and Types of Health Insurance, Columbia supplemental charges) increased approxi­ University (36). mately twice as fast as the national aver­ age (CPI). Yearly comparisons for this pe­ Utilization riod show that Kaiser's costs increased Kaiser members have lower hospitaliza­ more rapidly than the CPI in every year tion rates compared with other groups except 1964 and 1965 (42). Were all med­ when measured by total days of hospital ical care delivered through Kaiser-like care per 1,000 members per year. Kaiser's plans, health care costs would continue rate is lower in comparison with various their inflationary spiral. commercial insurance plans and certain "individual-practice type plans" such as Cost Reduction and Patient Control the San Joaquin Foundation for Medical In this society, medical services are like ZJare, and about half that of Blue Cross/ other commodities whose sale reaps 31ue Shield (37). Two factors, the rate of profits. Producers/providers at once control tdmissions and length of stay per admis- the supply and create the demand for the ion, are responsible for Kaiser's lower product. Unnecessary goods such as too ospitalization rates. many specialists, drugs and surgery are Kaiser also has a much lower rate of foisted upon people while actual needs ospital admissions for in-hospital surg- may go unmet. It is within this context ral procedures, about one-half that of that Kaiser's costs and utilization data lue Shield. Specifically, the rate is sub- must be considered. antially lower for tonsillectomies, "fe- In prepaid group practices such as ale surgeries," appendectomies, and Kaiser, the traditional financial incentives til bladder surgery (38). are reversed so that profit or savings Some authors suggest that one reason for physicians and hospitals alike can be spitalization is lower at Kaiser than achieved through minimizing, rather than th other plans is because more proce- maximizing, utilization of services. Given res are handled on an out-patient basis. that there is unnecessary hospitalization wever, studies show Kaiser's rate of and excessive surgery in "mainstream" bulatory utilization does not differ medicine. Kaiser's lower hospital utiliza­ (atly from the rate in other plans (39). tion and surgery rates are commendable. How does Kaiser achieve its lower utiliza­ ts tion rates? )n the average, Kaiser members do pay The National Advisory Commission on for the same benefits than members Health Manpower, for example, rejects >ther health insurance plans (40). Al- poor medical care, denial of services or igh premiums for Kaiser are often relatively good health of members as ex­ ter than for other plans, this is more planations of Kaiser's cost-savings. The i offset by smaller out-of-pocket Commission also rejects as explanations tnses. both innovations in the practice of med­ it families with incomes under $11,000 icine and economies of scale. They con­ i higher out-of-pocket expenditures clude that pressuring the physicians to be therefore greater total expenses than cost-conscious and "avoiding waste" re­ ies with incomes over $11,000. sult in savings. reas "higher income" families (over If the Commission is correct and control DO) have an average $49 out-of- of physicians is a major source of the )t expenditure, "lower income" fam- economies of Kaiser, several Kaiser doc­ average $112. This suggests that tors indicate that the methods and degree income families seek more care out- of pressure have an ultimately deleterious >f Kaiser because of dissatisfaction effect on the quality of care because of ause they haven't learned to use the their negative effects on the physician system (41). (see quality of care section).

17 Furthermore, contrary to the Commis­ References 1. The Big Foundations, Waldemar Nielsen, 20th Cen­ sion's conclusions, it appears there are tury Fund Study, Columbia University, 1973. pages 245-46. systematic mechanisms in the Kaiser sys­ 2. Kaiser Wakes the Doctors, Paul de Kruiff, 1948. 3. Chicago Sun, June 20, 1945. tem other than pressure on physicians 4. The Kaiser-Permanente Medical Care Program, A Symposium, Anne R. Somers, editor. The Common­ which discourage utilization. Roemer and wealth Fund, New York, 1971, page 13. his colleagues discussed the deterring ef­ 5. Washington Post, November 25, 1971. 6. DMS Market Intelligence Reports. fects of barriers created by the system's 7. Wall Street Journal. January 5, 1972. 8. Nielsen, op cit., page 247. bureaucracy. And as a Comprehensive 9. Ibid., page 248. 10. See section 37.59 Kaiser Hospital General Specifica­ Health Planning official said, "Kaiser uses tions, City Hall, Redwood City, California, February 15, 1966. several recognized methods for deterring 11. The Case For American Medicine, Harry Schwartz, 1972, page 174. utilization: copayments, long telephone 12. Somers, op cit., page 42. waits, inadequate waiting room size, shut­ 13. Ibid., page 38. 14. Ibid., page 42. ting down hours of operation, requiring a 15. Ibid., pages 138-148. 16. Health Insurance Ettects, Roemer, Hetherington, Hop­ series of tasks to obtain a prescription, kins, Gerst, Parson and Long, School of Public Health, The University of Michigan, 1972. and long waits for lab results." (43) 17. "Social Class Differences in Utilization of Pediatric Services in a Prepaid Direct Service Medical Care Pro­ In terms of costs to members. Kaiser gram," Nolan, Schwartz, Simonian, American Journal of Public Health, January, 1967. could economize in two ways. One is to 18. FeeJings About the Kaiser Foundation Health Plan on the Part of Northern California Carpenters and Their reduce the "profits," for example, by slow­ Families, April 5, 1973, CCHPA, 1870 Ogden Drive, ing expansion and eliminating the physi­ Burlingame, Cal., 94010. 19. Somers, op cit., page 16. cians' huge bonuses. The other is to re­ 20. Kaiser-Permanente Health Plan, Why It Works, Greer Williams, The Henry J. Kaiser Foundation, Oakland, duce the delivery of services. Kaiser is Cal., 1971, page 38. 21. Nolan, et al, op. cit., page 48. traveling the second route, one which can 22. Williams, op. cit., page 40. 23. Roemer, et al, op cit., page 45. be followed only so far before quality of 24. Ibid., page 32. 25. Nolan, et al, op cit., pages 38-40. care is jeopardized. As a private business, 26. Ibid., page 45. K-P will never take the first route. 27. Williams, op cit., page 48. 28. "An Evaluation of Prepaid Group Practice," Avedis Whether corporate HMO's develop in a Donabedian, Inquiry, Vol. VI, Number 3, pages 1-15. 29. Nolan, et al, op cit., page 42. significant way will depend on whether 30. Hearings Before the Subcommittee on Health of the Committee on Labor and Public Welfare, United profits are made. If Kaiser is any indica­ States Senate, Part 4, page 1484. 31. Somers, op cit., page 91. tion, the profits will be substantial. How­ 32. Personal Communication. ever, problems in the delivery of health 33. Roemer, et al, op cit. 34. The Federal Employees Health Benefits Program, care will remain. Others, such as over- 1971, studies utilization from 1961-68 in four different types of health insurance plans which were offered hospitalization and excessive surgery Federal employees and their families across the na­ tion. The four types are group practice (seven plans, may risk over-correction. With incentives four of them are Kaiser), the Blues, commercial plans, and what they call individual-practice plans, for the extreme it is not unlikely for many such as the San Joaquin Foundation for Medical Care. people to go un-hospitalized who should 35. The Report of the Medical and Hospital Advisory Council to the Board of Administration of the Cali­ be in hospitals. fornia State Employee's Retirement System (The Sacramento Study), presents data gathered for 1962- As seekers of health care, we will con­ 63 from California state employees who were mem­ bers of the same four different types of health insur­ tinue to pay the costs: monetary, phys­ ance plans as in the Federal study. ical and psychological. Budding HMO's 36. Family Medical Care Under Three Types of Health Insurance, Columbia University, 1962, compares the will fight-out their survival in the arena of 1958 experiences of members of Kaiser in northern California, New Jersey Blue Cross-Blue Shield, and competition and the small weaker ones a commercial plan. General Electric, in the Midwest. A major drawback of this study is that the data are will fail because of the huge initial capi­ now 15 years old. tal investments. Ultimately health care 37. Footnotes 33, 34, 35. 38. The Columbia study found a similarly low rate for will be delivered full force into the age of tonsillectomies at Kaiser, but found no differences in adult surgery rates. corporate capitalism. 39. Roemer, et al, op cit., pages 27-34. 40. Footnotes 33,34, 35. —Judy Carnoy, Lee Coffee and 41. Roemer, et al, op cit., page 45. Linda Koo. Lee and Linda were 42. Financial Study of the Kaiser Medical Care Program, Working Paper Number 12, Robert A. Vradiu, David B. summer interns at the San Fran­ Starkweather, and Alfred W. Childs, University of California, Berkeley, Unpublished manuscript. cisco office. 43. Personal communication.

American Assn. of Foundations of Medical Care— INDEX (Dec. 30, 1973) Feb. 73, p.8. American Assn. of Inhalation Therapists—Nov. 72, A pp.4-5. Abortion—Dec. '69, p.12; Mar. 70; Nov. 70. p.14; American Association of Medical Colleges—Jul.-Aug. Dec. 70, p.9; Feb. 73, pp. 10-11. '69, p.4. Addiction Services Agency—June 70, p.9. American Conf. of Gov't, and Industrial Hygienists— Affiliations—June '68; Aug. '68, p.5; Nov.-Dec. '68, Sept. 72. p.14; Winter '69; Jul.-Aug., '69, p.12; Apr. '69; American Hospital Assn.—Nov. 72, pp.7-9. Dec. 71; Sept. 73 (Montefiore-Prisons); Oct. 73 American Medical Assn.—Nov. 72, pp.3-4, 10-15. (NYU-Bellevue). American Natl. Standards Institute—Sept. 72. Air Pollution—Oct. 70, p.10. American Nurses Assn.—Nov. 72, pp. 8,11.

18 Asbestosis—Mar. '73. Feldstein, Martin—May '73, p.17. Assn. for Retarded Children—Jan. '73. Fordham Hospital—Nov.-Dec. '68, p.13; Jul.-Aug. '69, Attica Prison—Nov. '71; Sept. '73, pp.14-15 (Prison p.9. Health). Free Health Clinics—Apr. '71, p.6; Oct. '71; Feb. '72. B G Bellevue Hospital—Sept. '73 (Prison ward); Oct. '73. Ghetto Medicine Bill—Jan. '70, p.ll; Apr. '70, p.13; Beryllium Poisoning—Sept. '72, p.13. Jul.-Aug. '72. Beth Israel Hospital—Jul. '68, p.2; July-Aug. '69, p.10; Group Health Insurance (NY)—Oct. '72. Sept. '69, p.13; Apr. '70, p.14; Oct. '70, p.3; Jul.- Group Practice—Nov. '70, p.9; June '71, p.8. Aug. '72. Gouveneur Hospital—Jul. '68, p.2; Jul.-Aug. '69, p.10; Beverly Enterprises—Apr. '73, p.8. Nov. '69, p.10; Feb. '70, p.8. Biomedical Research—May '73. Birth Control—Apr. '72. H Birth Control Pills—Mar. '70, p.10; Apr. '72. Haight-Ashbury Free Clinic—Oct. '71; Feb. '72. Black Lung Disease—Sept. '71. Harlem Hospital—Jul. '68, p.4; Nov.-Dec. '68, p.9; Blue Cross—Jul.-Aug. '69, p.ll; Sept. '69; Oct. '69, June '69, p.12; Dec. '70, p.6. p.10; Mar. '71, p.l; Jul.-Aug. '72; Oct. '72, pp.19- Harlem Medical School Proposal—Oct. '72, pp.7-9. 20, 23. Harrington, Donald—Feb. '73, p.4. Boston City Hospital—Jul.-Aug. '70, p.15; Oct. '73. Harvard Medical School—Jan. '71, p.2. Boston University Medical Center—Oct. '73. HEW—Mar. '71, p.10; May '73. Brian, Earl—Apr. '73, p.16. Health and Hospitals Corporation—Winter '69, pp.1-4; Brindle, James—Oct. '72, p.17. June '69, p.12; Sept. '69, p.7; Nov. '69, p.10; Jan. Buffalo Medical School—Nov. '71. '71, p.9; Dec. '71; Feb. '72; May '72. Bureau of Occupational Safety and Health—Sept. '72. Health and Hospitals Planning Council—June '68; Byssinosis—Sept. '72, pp.20-23. Winter '69; Jul.-Aug. '69; Sept. '69, p.4; Apr. '71, p.5; May '72, p.5; May '73. c Health Inc., Boston—Mar. '72. California Public Hospitals—Apr. '73. Health Insurance Plan of Greater NY—Oct. '72, Carnegie Foundation—Nov. '71. pp.15-22; Dec. '72. Case Western Reserve Med. School—Jan. '70, p.12; Health Maintenance Organizations (HMO's)—Nov. Sept. '71. '70; Apr. '71, p.l; Dec. *71; Jul.-Aug. '72; Oct. '72, Center for the Prevention of Violence—Sept. '73. pp.15-22 (HIP); Feb. '73 (Foundations); Nov. '73 Certified Hospital Admission Program—Feb. '73, p.7. (Kaiser). Cherkasky, Dr. Martin—Apr. '69. Health Planning (see Health and Hosp. Planning Chicago Health Movement—Apr. '71, p.6. Council)—June '68; Winter '69; Jul.-Aug. '69; Apr. Children's Hospital, Boston—Mar. '72. '71, p.5; May '72, p.5. Chinese Health System—Dec. '72. Health Professions Educational Assistance—Nov. '71; Cincinnati People's Health Movement—Sept. '71. May '73, p.10. City University of NY Proposal (Med. School)—Oct. Health Revolutionary Unity Movement (HRUM)—Feb. '72, pp.11-13. '70, p.9; Jul.-Aug. '70, p.12; Sept. '70, p.13; Oct. '70, City wide Save-Our-Homes Committee (NY)—May '72, p.l; Dec. '70, p.9; June '71, p.10; Jan. '72; Jul.-Aug. pp.4-7. '72. Cleveland Health System-Sept. '71. Health Services Administration—Jul. '68, p.l; Sept. Coler Hospital Oct. '69, p.2. '68, p.l; Sept. '69, p.8; Nov. '69, p.ll; Jan. '70, p.10; Columbia Medical Center -Jul. '68; Aug. '68; Nov.- May '72; Sept. '73 (Prisons). Dec. '68; Jul.-Aug. '69, p.10; Sept. '69, p.ll; Dec. Hill-Burton—May '72, p.l; Jul.-Aug. '72; May '73, p.8. '69; Feb. '70; Oct. '70, p.9; Dec. '70, p.6; Mar. '71, Hilton Davis Co. (strike)—Sept. '71, p.5. p.9. Hospital Costs—Jan. '70, p.7; Nov. '70, p.4; June '71; Columbia Hospital—Nov. '71. May '72, p.3; Jul.-Aug. '72. Columbus Hospital (NY)—Nov. '71, pp.10-12; May Hospital Expansion—Nov. '71; Mar. '72; May '72. '72, p.6; Oct. '72, p. 24. Hospital Worker Unions—Jul.-Aug.'70; Sept.'70, p.16; Committee of Interns and Residents- Aug. '68; Sept. June '71, p.6; Sept. '71; Oct. '72, pp.9,23; Nov. '72, '69, p.15. p.6. Community Control—Oct. '68; Nov.-Dec. '69, pp.1,5; Jan. '72; June '72. I Community Medical School Proposal (Lincoln)—Oct. Industrial Health Foundation—Sept. '72. '72, pp.10-11. Industrial Medical Association—Sept. '72. Community Mental Health—Aug. '68, p.4; Apr. '69, Institutional Licensure—Nov. '72, pp. 7-8. p.13; May '69 (Lincoln); Dec. '69. Insurance Companies—Nov. '69, p.6; Jul.-Aug. '72. Community Mental Health Board (Dept. of Mental Irvington House—Mar. '71, p.4. Health)—May '69; Dec. '69. I Wor Kuen—Oct. '70, p.4. Community Mental Health Centers—May '73, p.9. Coney Island Hospital- May '72, p.8. I Consultants—Oct. '70, p.ll. Johns-Manville Corp.—Mar. '73. Cook County Hospital- Apr. 73, p.7. Joint Committee on Accreditation of Hospitals (JCAH) Cornell/New York Hospital- Sept. '69, p.ll. - Feb. '72; Apr. '73. Judson Mobile Unit—Nov. '69, p.ll. D Davis Medical School (Univ. of Calif.)—Apr. '73, K pp. 10-11. Kaiser-Permanente—Nov. '70, p.12; Nov. '73. Delafield Hospital—Nov.-Dec. '68, p.8; May '72, p.8. Key, Dr. Marcus—Sept. '72, p.13. Downstate Medical Center—Sept. '69, p.13; Oct. '70, King General Hospital—Apr. '73, p.6. Knickerbocker Hospital—Nov.-Dec. '68, p.8; Oct. '72, pp.7-9. Einstein-Montefiore—Apr. '69; Sept. '69, p.9; Sept. '70, L p.12; Oct. '70 p.l; Jan. '71, p.6; Nov. '71; May '73 Lead Poisoning—Sept. '68, p.2; Apr. '70, p.13; Jan. (Einstein); Sept. '73 (Montefiore-Prisons). '71, p.8. Ellwood, Dr. Paul—Jul.-Aug. '72. Licensure—Nov. '72, pp. 3-9. Lincoln Hospital—Apr. '69; Sept. '70, p.12; Oct. '70, F p.l; Dec. '70, p.9; Jan. '71, p.6; Jan. '72; Jul.-Aug. Federal Health Policy—Nov. '70; Apr. '71, p.l; May '72. '73. Lincoln Community Mental Health Center—May '69; Federation of Jewish Philanthropies—Apr. '69, p.9. Sept. '69, p.10.

19 Logan, Dr. Arthur—Oct. '72, pp.7-9. Physician's Assistants—Nov. '72, pp.10-16. Lower East Side Neighborhood Health Council— Piel Commission Report—June '68, p.4; Winter '69, South (LESNHCS)—Jul. '68; Jul.-Aug. '69; Sept. p.7. '69, p.14; Feb. '70, p.8; Apr. '70, p.14; Jul.-Aug. '70, Planners—Jul.-Aug. '68, p.8. p.12; Oct. '70, p.4. Prepaid Health Plans (PHP's)—Feb. '73, p.14, Apr. M '73, p.18. Madera County Hospital—Apr '73, p.6. Prisons—May '70; Nov. '71; Sept. '73. Maimonides Community Mental Health Center—May Professional Standards Review Oraanizations '68, p.8. (PSRO's)—Feb. '73, p.12. Martin Luther King Health Center—Oct. '69, p.3. Psychiatry—May '69, p.12; May '70. Maternal and Child Care—May '73, p. 10. Public Health Hospitals—Mar. '71, p.8. Maximum Liability Health Insurance—May '73, p.17. Q Medicaid—Winter '69; June '69; Sept. '69, p.6; Jul.- Queens Medical School Proposal—Oct. '72, pp.6-7. Aug. '72; Oct. '72, p.16; Feb. '73, p.10 (Medi-Cal); Apr. '73 (Medi-Cal); May '73. R Medicaid Mills—Jul.-Aug. '72. Regional Medical Programs—Jul.-Aug. '69, pp. 1,3; Medical Empires—Nov.-Dec. '68; Apr. '69; Sept. '69, May '73, p.9. p.9; Oct. '70; Apr. '73 (Calif.). Research Guide—Feb. '71. Medical Industrial Complex—Nov. '69. Medical Imperialism—Apr. '70, p.8. s Medical School Income—Nov. '71, p.5. Sacramento County Hospital—Apr. '73, p.9. Medical School Proposals (NYC)—Oct. '72. Sacramento Foundation for Medical Care—Feb. '73, Medicare—June '69, p.8; Nov. '69, p.7; Jul.-Aug. '72; p.7. May '73. Sacramento Medical Center—Apr. '73, pp.10-11. MEGA—May '73, p.14. San Francisco General Hospital—Jul.-Aug. '70, p.17; Mental Retardation—Jan. '73. Mar. '71, p.7; Feb. '72; Feb. '73, p.15; Apr. '73. pp. Merced County Hospital—Apr. '73, p.8. 20-24; Sept. '73 (Prison ward). Methadone—June '70, pp.9,15. San Joaguin Foundation for Medical Care—Feb. '73, Methodist Hospital—Apr. '72. p.4. Metropolitan Hospital—Feb. '70. Seaview Hospital—May '72, p.ll. Michelson, William—Oct. '72, pp.19-21. Selikoff, Dr. Irving—Sept. '72, p.14; Mar. '73, p.3. Military Medicine—Apr. '70; June '71, p.4. Shell Chemical Co. (No Pest Strip)—Sept. '71, p.5. Morrisania Hospital—Apr. '69; May '72, p.8. Siskiyou County Hospital—Apr. '73, p.9. Mt. Sinai Medical Center—Oct. '70, p.7. Smith, David—Oct. '71; Feb. '72. Moore, Dr. Cyril—Oct. '72, p.ll. Social Workers—Sept. '70, p.ll. MOTF (Mayor's Organizational Task Force on CHP) Soundview-Throgs Neck-Tremont Comm. Mental Health —Apr. '71, p.5. Center—May '69, p.8. Municipal Hospital System (Cutbacks: NYC)—Win­ Stahl, Dr. William—Oct. '72. pp.11-13. ter '69; June '69. Staten Island—Mar. '71, p.8. N Sterling Drug Co.—Sept. '71, p.5. National Free Clinic Council—Oct. '71; Feb. '72. Student AMA—Mar. '70, p.14; Sept. '70, p.2. National Medical Enterprises—Apr. '73, p.8. Student Health Organization (SHO)—Aug. '68, p.3; National Institute for Occupational Safety and Health Mar. '70, p.14; Sept. '70, p.4. —Sept. '72; Mar. '73. St. Joseph's Mercy Hospital (Ann Arbor)—Oct. '72, National Safety Council—Sept. '72. p.14. Narcotics—June '70; Dec. '70, pp.6,9; Jan. '72, pp.8,9. St. Vincent's Hospital—Jan. '70, p.12; Mar. '71, p.6; National Health Corps—Apr. '70, p.9. Jul.-Aug. '72. National Health Insurance—June '69, p.7; Jan. '70; Sydenham Hospital—Nov.-Dec. '68, p.8. May '73. p.19. T National Institutes of Health (NIH)—May '73, p.ll. Taxes—June '71. Neighborhood Health Center June '72; May '73, p.10. Therapeutic Communities—June '70, pp.9,15. NENA (Northeast Neighborhood Assn.)—Jul. '68, p.l; Think-Lincoln—Sept. '70, p.13; Oct. '70, p.l; Jan. '71, Aug. '68, p.13; Oct. '70, p.4; June '72. p.6. New York City Prisons—Sept. '73. Thursday Noon Committee—Feb. '72; Apr. '73. New York Infirmary June '72, p.4. Tunnel Workers—Oct. '70, p.10. New York Medical College—May '69, p.9 (Commun­ Trussell, Dr. Ray—Nov.-Dec. '68, p.10; Apr. '70, p.14; ity Mental HealthCtr.); Sept. '69, p.l2;Oct. '70, p.6. Jul.-Aug. '72. New York Times- Feb. '70, p.ll; May '70, p.13. New York University Medical Center- Sept. '69, p.13; u Apr. '70, p.7 (Bennett); Oct. '70, p.3; Mar. '71, p.4; UCLA Medical Center—Jul-Aug. '70, p.16; Sept. '73. June '72, p.4; Sept. '73 (Prison ward); Oct. '73. United Harlem Drug Fighters—Oct. '70, p.ll; Dec. Nixon, Richard—Nov. '70; Apr. '71, p.l; May '73. '70, p.6. North Central Bronx Hospital—May '72, p.8. Nursing—Mar. '70; Sept. '71, p.l; Apr. '72; Sept. '72 V (letter); Nov. '72, p.16. Valley Medical Center—Apr. '73, p.6. Nursing Homes—Nov. '69, p.7. Vanderbilt Clinic—May '70, p.7. Veterans Administration Hospitals—Apr. '70, p.5; o May '71, p.9. Occupational Health—Feb. '70, p.5 (GE); May '71, Vietnam—May '71; Oct. '72, p.24. p.6; Sept. '71, p.5; Sept. '72; Mar. '73. Voluntary Hospitals—Oct. '69, p.9 (Cutbacks). Occupational Safety and Health Act—Sept. '72, pp. 15-19. w Occupational Safety and Health Administration— Walsh-Healy Act—Sept. '72, p.15. Sept. '72. Washington Heights-Inwood Community Mental Health Office of Management and Budget (OMB)—May '73, Center—Nov.-Dec. '68, p.9; Apr. '69, p.10; Dec. '69. p. 15. Weinberger, Caspar—May '73, p.15. Oil, Chemical and Atomic Workers Union—Oct. '72, Wesley Hospital (Chicago)—Jul.-Aug. '70, p.16. p.23. Willowbrook State School—Jan. '73. P Women's Health—Mar. '70; Apr. '72; Dec. '72. Patients' Rights—Oct. '69. Y Peace Movement—May '71, p.6. Yolo General Hospital—Apr. '73, p.6. Pediatric Collective—Oct. '70; Jan. '71, p.6; Jan. '72. Young Lords—Oct. '69, p.4; Feb. '70, p.9; Sept. '70, Peer Review—Feb. '73, p.5. p.13; Oct. '70, p.l; Dec. '70, p.9; Jan. '72.

20