Regional Oral History Office University of California The Bancrof t Library Berkeley, California Kaiser Permanente Medical Care Program Oral History Project Morris F. Collen, M.D. HISTORY OF THE KAISER PERMANENTE MEDICAL CARE PROGRAM An Interview Conducted by Sally Smith Hughes 1986 Copyright @ 1988 by the Regents of the University of California Since 1954 the Regional Oral History Office has been interviewing leading participants in or well-placed witnesses to major events in the development of Northern California, the West,and the Nation. Oral history is a modern research technique involving an interviewee and an informed interviewer in spontaneous conversation. The taped record is transcribed, lightly edited for continuity and clarity, and reviewed by the interviewee. The resulting manuscript is typed in final form, indexed, bound with photographs and illustrative materials, and placed in The Bancroft Library at the University of California, Berkeley, and other research collections for scholarly use. Because it is primary material, oral history is not intended to present the final, verified, or complete narrative of events. It is a spoken account, offered by the interviewee in response to questioning, and as such it is reflective, partisan, deeply involved, and irreplaceable. All uses of this manuscript are covered by a legal agreement between the University of California and Morris F. Collen, M.D., dated December 3, 1986. The manuscript is thereby made available for research purposes. All literary rights in the manuscript, including the right to publish, are reserved to The Bancroft Library of the University of California, Berkeley. No part of the manuscript may be quoted for publication without the written permission of the Director of The Bancroft Library of the University of California, Berkeley. Request for permission to quote for publication should be addressed to the Regional Oral History Office, 486 Library, University of California, Berkeley 94720, and should include identification of the specific passages to be quoted, anticipated use of the passages, and identification of the user. The legal agreement with Morris F. Collen, M.D., requires that he be notified of the request and allowed thirty days in which to respond. It is recommended that this oral history be cited as follows : Morris F. Collen, M.D., "History of the Kaiser Permanente Medical Care Program," an oral history conducted in 1986 by Sally Smith Hughes, Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 1988. Copy No. TABLE OF CONTENTS -- Morris F. Collen, M.D. PREFACE INTERVIEW HISTORY BRIEF BIOGRAPHY viii FAMILY BACKGROUND AND EDUCATION Grandparents, Parents, Brothers, and Sister Early Education University of Minnesota Medical School, 1934-1938 Internship at Michael Reese Hospital, Chicago, 1938-1940 Residency at Los Angeles County General Hospital, 1940-1942 Raymond Kay Sidney Garf ield Cecil Cutting I1 PHYSICLCLY IN THE PERMANENTE MEDICAL GROUP, NORTHERN CALIFORNIA The Wartime Medical Program in Oakland Assignment and Early Experiences Fabiola Hospital Foundation of the Entities Composing the Medical Program Internal Medicine Intern and Resident Training Programs Permanente Foundation Medical Bulletin and Kaiser Foundation Research Institute Physician Recruitment Pneumonia Millie Cutting Physician Salaries Chief of Medicine The Immediate Postwar Years The Health Plan Goes Public Labor Unions Forming the Medical Partnership Terminology: Chief of Staff, Medical Director, Physician in Chief Garfield's Withdrawal from the PMG Opposition from Fee-For-Service Medicine The PMG Executive Committee Communists in the PMG Medical Director, Kaiser Foundation Hospital, Oakland, 1952-1953 55 Medical Director, Kaiser Foundation Hospital, San Francisco, 1953-1979 56 Drs. Benjamin Feingold and Bristol Nelson 57 Relations with Other Medical Organizations 58 The 515 Market Street Clinic 59 The Administrative Staff 60 The Medical Staff 64 Dr. Collen as Physician-Administrator 65 Tensions Leading to the Tahoe Conference 67 Bess Kaiser 6 7 Garfield's Role 68 Walnut Creek 70 Monte Baritell's Resignation 73 Clifford Keene 77 Opposition from Organized Medicine 81 The Executive Committee of the Permanente Medical Group 86 The Tahoe Period 93 Disagreements Between the Physicians and Health Plan/~os~it~l~93 Leadership Styles 101 Physical and Social Stresses 10.3 The Tahoe Agreement 105 The Northern California Technical Team 108 Edgar Kaiser and Eugene Trefethen 111 Further Comments 112 The Post-Tahoe Period 117 Regional Management Teams 117 Organizational Relationships 120 The Trefethen Initiative 122 The Medical Service Agreements 126 The Kaiser Permanente Committee 129 Problems in Hawaii 130 Executive Director of the Permanente Medical Group 132 Prelude to San Diego 137 Garfield's Removal as Medical Director 138 The Permanente Medical Group's Venture in San Diego 141 The Eden Medical Group 147 Paul and David De Kruif 150 The Central Office 151 Medicare and Medi-Cal 153 Expansion of the Kaiser Foundation Hospitals and Health Plan Boards 154 The Physician-Patient Ratio 155 Royf ield and Dapite 157 The Kabat-Kaiser Institutes 158 Kaiser Foundation Hospital , Vallej o 160 The School of Nursing 162 Physicians' Forums and the Kaiser Permanente Committee 164 The Executive Committee of the Permanente Medical Group 165 DIRECTOR, DEPARTMENT OF MEDICAL METHODS RESEARCH, 1961-1979 Multiphasic Health Screening The Department of Medical Methods Research Formation The Public Health Service Grant Criticisms of Multiphasic Health Screening The Health Services Research Center The Medical Care Delivery System Project The Department Today Medical Computing Elsewhere The Food and Drug Administration Contract Use of the Multiphasic Data Base Relationships with the Computer Industry Training Programs and Visitors MISCELLANEOUS TOPICS Director, Division of Technology Assessment, 1979-1983 Prioritizing Research, Teaching, and Patient Care Garfield's Total Health Care Program Honors Dr. Collen's Ten Commandments Discrimination in the PMG Patient Scheduling Mental Health Care in the PMG Honoring Garfield Dr. Collen's Contributions TAPE GUIDE APPENDIX - A. Curriculum vitae B. Bibliography C. Two letters regarding Dr. Collen's employment by Dr. Garfield. Two letters regarding Dr. Collen's military service during World War 11. He was assigned to Kaiser's Richmond shipyard. Minutes of the Permanente Medical Group's executive committee regarding the appointment of Dr. Cutting as first executive director of the Permanente Medical Group and describing the director's responsibilities. Minutes of the executive committee regarding the termination of the San Diego venture and establishing the Department of Medical Methods Research. Documents regarding Dr. Collen's retirement from the executive committee, including his "Ten Commandments." BIBLIOGRAPHY INDEX INTERVIEWS KAISER PERMANENTE MEDICAL CARE PROGRAM David Adelson Morris Collen, M.D. Wallace Cook, M.D. Cecil C. Cutting, M.D. Alice Friedman, M.D. Lambreth Hancock Frank C. Jones Raymond M. Kay, M.D. Clifford H. Keene, M.D. Benjamin Lewis, M.D. George E. Link Berniece Oswald Sam Packer, M.D. Wilbur L. Reimers, M.D. Ernest W. Saward, M.D. Harry Shragg, M.D. John G. Smillie, M.D. Eugene E. Trefethen, Jr. Avram Yedidia PREFACE Background of the Oral History Project The Kaiser Permanente Medical Care Program recently observed its fortieth anniversary. Today, it is the largest, one of the oldest, and certainly the most influential group practice prepayment health plan in the nation. But in 1938, when Henry J. and Edgar F. Kaiser first collaborated with Dr. Sidney Garfield to provide medical care for the construction workers on the Grand Coulee Dam project in eastern Washington, they could scarcely have envisioned that it would attain the size and have the impact on medical care in the United States that it has today. In an effort to document and preserve the story of Kaiser Permanente's evolution through the recollections of some of its surviving pioneers, men and women who remember vividly the plan's origins and formative years, the Board of Directors of Kaiser Foundation Hospitals sponsored this oral history project. In combination with already available records, the interviews serve to enrich Kaiser Permanente's history for its physicians, employees, and mem- bers, and to offer a major resource for research into the history of health care financing and delivery, and some of the forces behind the rapid and sweeping changes now underway in the health care field. A Synopsis of Kaiser Permanente History There have been several milestones in. the history of Kaiser Permanente. One could begin in 1933, when young Dr. Sidney Garfield entered fee-for- service practice in the southern California desert and prepared to care for workers building the Metropolitan Water District aqueduct from the Colorado River to Los Angeles. Circumstances soon caused him to develop a prepaid approach to providing quality care in a small, well-designed hospital near the construction site. The Kaisers learned of Dr. Garfield's experience in health care financ- ing and delivery through A. B.' Ordway, Henry Kaiser's first employee. When they undertook the Grand Coulee project, the Kaisers persuaded Dr. Garfield to come in 1938 to eastern Washington State, where they were managing a consortium constructing the Grand Coulee Dam. Dr. Garfield and a handful of young doctors, whom he persuaded to join him, established a prepaid health plan at the damsite,