GROWING IN THE KAISER ORGANIZATION
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SCPMG is one of the largest multi-specialty group practices in the nation, with 3,000 plus partner physicians, it prides itself on its camaraderie and close-knit team approach to medicine. Playing an important role in this system is the Family Medicine Department. With 40-plus physicians and a number of support staff, Family Medicine is the largest of the hospital's departments and location of the only residency training program in the Riverside area. The department benefits from its close affiliation with the Riverside Medical Center Hospital as well as numerous connections throughout the Kaiser network.
| PRACTICE SUMMARY CHART | |
| Type of Practice | Integrated System/Suburban |
| Physicians | 48 in the Family Medicine Department at 4 different offices, with 3 physicians in each Clinic Module or team |
| Additional Providers | 12 NP/PAs in Family Medicine, with 1 NP/PA in each Clinic Module |
| Yearly Patient Visits | Approximately 3,300 for Dr. Chu |
| Yearly # of Deliveries Annually | 10 for Dr. Chu |
| Additional Employees | Approximately 70 overall in the Family Medicine Department, with 3 in each Clinic Module |
| Other Health Professionals | The Family Medicine Department works with a wide range of professionals throughout the Center |
| Affiliations with Hospitals |
Riverside Medical Center Hospital; USC School of Medicine (for Residency Training Program) |
| Residents | 18 total; 6 per year |
| Medical Students | Not applicable |
Mid-level providers/nurses/other allied health professionals are responsible for initial patient physicals, healthy adult physicals, and walk-in visits for minor problems. Additionally, the above personnel assist with follow up for chronic medical conditions such as diabetes management, hypertension, asthma, congestive heart failure, cholesterol and Coumadin management. Services such as lab testing, bone density, ultrasound, colonoscopy and screenings are all available at the hospital adjacent to the Family Medicine clinic.
Due to the fact that Kaiser is a vertically integrated health care system, Dr. Chu's hospital interaction is all within Kaiser, and arranging services is rather hassle-free. Interaction with the larger health care community only occurs if patients receive care from an outside provider or request services that are not provided by Kaiser.
Compensation and Benefits
KP physician compensation involves a two-step process: (1) the health plan pays the medical group; and (2) the medical group pays the physicians. Each year Kaiser Health Plan and the Kaiser Permanente Medical Group in each region negotiate and agree on the total amount of money they estimate will enable physicians to provide the amount of professional medical care that members are expected to need in the upcoming year. This estimate is based on the previous year's performance (and the years prior to that), and also includes administrative and other expenses associated with operations. That total is divided by 12 months and then divided by the number of expected members in the coming year. That calculation results in an amount of money (the "capitation") the health plan pays to the medical group on a monthly basis for each member. In addition, the health plan reimburses the medical group for its actual cost for certain medical and other expenses that may be difficult to forecast, such as transplants and contingent expenditures. The total is called the "basic contractual payment."
The primary compensation method used by all of the Medical Groups is salary. Salary generally varies with medical specialty and tenure. Smaller amounts of additional compensation may be paid for, among other things:
- Board certification
- Achievement of specified clinical quality measures
- Achievement of member satisfaction levels
- Productivity
- Continuing medical education
- Managerial work
- Work performed in excess of normal work time, etc.
According to Dr. Chu family physicians who are SCPMG partners earn between $140,000 and $240,000 after 20 years or more. As a group practice SCPMG offers certain benefits such as health, disability, and life insurance, as well as 401(k), Keogh and a "Common Plan" sponsored by the Kaiser Foundation Health Plan/Hospitals for retirement. Since Kaiser Permanente is self insured there are no costs for professional liability insurance.
Hours/Practice Flexibility
Kaiser Permanente schedules health care providers using a 10-part schedule that is equivalent to 10 one-half days a week. Dr. Chu works 6/10 time in the clinic, one-half day a week doing sigmoidoscopies, one half-day mentoring residents, one-half day attending to residency issues, including his OB duties and administrative meetings, and he has one afternoon for education time. There is an expectation that providers will see 12-13 patients per unit. He typically starts at 8 am and sees patients until 5 pm. By the time he deals with referrals, call, charts and other business, he usually leaves the office about 7 in the evening.
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PRACTICE: WEEK-AT-A-GLANCE
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Dr. Chu does rounds in the hospital for seven continuous days approximately every two months. Coverage of family medicine patients is rotated with this same rounding schedule. When asked about flexible hours and schedules Dr. Flowers, Chair of the Department of Family Medicine, responds that flexible scheduling and part-time work are not really a part of the Kaiser tradition, but the culture is changing to be more accommodating.
Employees
Southern California Kaiser Permanente employees receive a standardized compensation and benefit package based on their position and seniority. One of the benefits of a large organization is the many training opportunities and room for growth within the organization. Also, there is preference given for KP employees as they transfer within the larger organization. Many of the staff appreciate these opportunities for growth and change that they might not have in a smaller organization.
Balance
"I'd like to downshift a little," Dr. Chu says. Between his very difficult patient load, his leadership with KP-APAN, and other commitments he is gone at least two nights a week. Having a passion for teaching and diversity issues has driven Dr. Chu to take on additional responsibilities in these areas. However, the need to face the reality of how many hours he has available to accomplish these tasks forces him to reconsider how much he can take on.
The practice looks for employees who show dedication and commitment to patient care, as well as passion for their work. Dr. Chu thinks the transition from a Kaiser residency to associate is relatively easy: "I did my residency here, my mentor was here, and it was an easy transition. I very much liked patient care, but didn't want to worry about the business aspects of medicine."
The practice has had physicians leave before making partner and, as a result, learned two key lessons. First, it is important to find those who fit the type of practice SCPMG offers. Specifically, this is defined as a stable group practice with generous benefits but less potential "profit/income," more limited work hours, fewer overhead/bureaucratic complications, and a large company culture. Secondly, the practice now recognizes the need for flexibility when working with pre-partners in terms of schedules, workload, salary and staff issues.
When welcoming a new physician to the practice, Kaiser Riverside helps promote and establish his or her relationship with fellow SCPMG physicians in a number of ways. The practice develops mentoring relationships and programs, involves the new hire in SCPMG/Kaiser group activities and projects, and formally introduces him or her to the medical group.
Due to the large Latino population Spanish-speaking providers are an important asset at Riverside Medical Center. Other community needs include low-income health care and chronic disease management. These needs are identified by the public affairs office's contacts with the local community and are met by the group through community outreach events, well-child physicals at needy schools, sports physicals and after-school programs. Dr. Chu contributes personally by working with residents at the medical center doing school and sports physicals, and performing health screenings at local events.
Mentor, volunteer and work programs are also established at the junior high, high school and college levels respectively. For example, Riverside Medical Center sponsors a Hippocrates Circle for 27 students at Villegas Middle School. This is the first physician mentoring program for middle school students in the Inland Empire. At these events students meet their physician mentors, and they and their parents participate in programs designed to help them visualize and prepare for a career in medicine.
Dr. Chu actively takes part in numerous community organizations. As President of the KP-Asian Pacific American Network (KP-APAN), Dr. Chu is involved with community service, professional development and community liaison activities. Kaiser staff associations also provide expert, culturally specific feedback to physician and administrative leadership on health issues affecting the Asian and Pacific American community. Dr. Chu has formerly served as Vice-President of the Inland Chinese Association, as well as serving on its community diversity group-Coalition for Common Group. Currently, he is a deacon at his church, the Evangelical Formosan Church of the Inland Empire.
If there is one area that Dr. Chu would like to improve it is being even more prepared for his patients. "Since I have patients with very complex conditions, often involving chronic pain, I need to be more intentional about my interactions with them," explains Dr. Chu. He wants to be more systematic in dealing with ongoing requests for referrals, prescription refills and patient calls so that he is "more present" when he is with each individual patient.
SCPMG partners have the ability to take a sabbatical leave after five or 10 years, and Dr. Chu is considering taking that time to study acupuncture or go on a medical mission. Meanwhile, he plans to prepare himself to become more involved in the residency program. On a day-to-day basis he listens to audio CME in his car. He also attends CAFP and AAFP Scientific Assemblies annually.
Kaiser Permanente has an extensive quality improvement program involving patient satisfaction measures, peer evaluations and evaluations by supervisors. Patients are queried about all aspects of their Kaiser experience and these satisfaction scores are provided to each physician monthly. On a scale from one to ten, patients answer questions such as:
- How well did this doctor or health care provider explain to you what he or she was doing and why?
- Did this doctor or health care provider spend enough time with you?
- Overall how satisfied are you with the service you received from this doctor?
Colleagues evaluate one another annually according to professional skill, physician relationships with the SCPMG, practice habits and accessibility. Each partner can select those colleagues who will evaluate him or her, and likewise, each partner can choose whom to evaluate. Each partner is also evaluated by his physician chief according to similar criteria.
There are Kaiser-approved protocols for most major diagnoses and Kaiser also uses HEDIS measures for immunization, pneumonia vaccinations, diabetes control and coronary artery disease, to name a few. Each physician receives monthly care management reports that report on the standard of care for various diagnoses. As Dr. Flowers says, "We have clinical strategic goals and comparative information is given to individual providers so they always know where they need to improve with asthmatics, diabetics, vaccinations and those with coronary artery disease, for example."
Relationships with Other Specialists
One of the advantages of the Kaiser Permanente system is the access to very good specialty care at the hospital or nearby at another Kaiser facility. A referral is made (often electronically) to the appropriate department, which then places the patient with the right specialist. If a patient needs or wants to go outside the Kaiser system the referral needs to be approved by the family medicine chief.
Relationships with Other Health Providers
Dr. Chu is familiar with acupuncture and herbal medicine and uses both as a complement to traditional medicine. In particular he recommends acupressure and herbal medicines for patients with fibromyalgia, and for hormone replacement.
Relationships with University/Other Educational Settings
The residency program is affiliated with USC School of Medicine and the physicians who mentor the residents serve as clinical faculty of USC School of Medicine. Students from Loma Linda University also rotate through the department.
Relationships with Medical Students and Residents
Dr. Chu serves as one of the four physicians who work with residents from the Kaiser Riverside Residency Program. He enjoys working with them and says that if he had a chance, he would work with residents more. This is also one of the reasons he stays up to date with OB and has trained to assist with cesarean sections. One resident says, "Kaiser is a great experience because you get a real feel for practicing medicine in a community, the attendings are very available, and residents are really tight as a group." Dr. Chu also occasionally works with students from Loma Linda University teaching whole person care, including the spiritual health of his patients.
KP currently uses an old DOS-based system to track patients. By 2008, Kaiser Permanente's electronic health records system will put the program's 12,000 doctors and 8 million patients online within a single software infrastructure. Doctors and nurses using KP HealthConnect will have real-time access to their patients' medical information online in the exam room. They will know about patients' current and past medical conditions, the drugs they are taking, their allergies, and be able to order procedures, prescriptions and referrals right in the exam room. The supplier, Epic, says that it will provide Kaiser Permanente with a data depository that integrates all clinical data, including patient charts, order entry systems, clinical notes, nursing documentation and pharmacy information systems, and will provide medical staff with up-to-the-minute records, including test results.
Patient Communication
Kaiser Permanente has a sophisticated website that encourages member access to all types of health information, health encyclopedias and chat rooms. Patients can schedule appointments and request prescription refills online. Dr. Chu appreciates the fact that he can direct his patients to the website for credible information about their individual conditions. He also e-mails consultants and other physicians in the KP system.
Knowledge Management Technology
Dr. Chu has easy access to his computer to assess the latest information that might affect his decisions about a particular patient. He regularly consults Micromedex, MD Consult, UpToDate, the AAFP website and internal Kaiser websites.
Kaiser will be incorporating evidence based protocols into its new HealthConnect program and the Riverside doctors are intrigued by these possibilities for improving patient care.
Practice Management
Riverside Medical Center and Riverside Hospital are managed by Kaiser Permanente health administrators. As with any very large organization, there are separate administrative departments for human resources, legal, finance, marketing, communications and public affairs.
Governance/Physician Leadership
As the exclusive provider of medical services to Southern California Kaiser Permanente, SCPMG is a large group practice of self-employed physicians. After three years, associates are considered for partnership. Physicians are accepted into partnership by a vote of the physicians in their Center, and, according to Dr. Chu, one in 10 do not make it. But once selected as a SCPMG partner, very few leave. SCPMG has Bylaws and all partners have voting rights for partnership issues, including compensation and benefits.
SCPMG leadership is chosen at the local level by partner physicians, who elect representatives to the Board, as well as the SCPMG Medical Director, who leads the Medical Group. Area Medical Directors (for each medical center) are appointed by the Medical Director and ratified by the partnership at each medical center. Chiefs of Departments are appointed by Area Medical Directors and ratified by the department members.
Marketing
A new advertising campaign called "Thrive" was unveiled this past summer and was widely promoted at Riverside. Senior executives gave employees buttons and oranges as they entered Riverside Medical Center. The purpose of the campaign is to change the way the public views Kaiser Permanente. KP's new campaign, which includes TV, radio and print ads, shows consumers that its services will maximize their well-being and allow them to live a happier, healthier life. The new campaign reinforces a broad definition of health, one that is emotional and includes mind, body and spirit. In addition to treatment and traditional medicine the campaign emphasizes a partnership to maintain healthy choices and attitude around nutrition, exercise, psychological well-being and life balance. As Dr. Chu says, "This campaign makes health care more of a team effort and a joint responsibility between the physician and patient."
Coverage/Relations with Payers
Since Kaiser Permanente Southern California is a staff model HMO it is the "payer" for medical and health services. Kaiser has a contract with Medi-Cal and also with Medicare. Since Kaiser has found that some consumers are looking for affordable options, as opposed to the single premium for comprehensive benefits that has been Kaiser Permanente's hallmark, it is rolling out a new deductible, low premium plan for individuals. This marks the first step in a plan that will include offering deductible products to other member groups over the next several months.
Reimbursement
Kaiser Permanente payer mix is as follows: 2% Medi-Cal; 9% Medicare; and 89% KP Health Plans. Kaiser is interested in offering new products which it hopes will expand its market share.
| Primary Contact: | Francis Chu, MD |
| Kaiser/Riverside Medical Center | |
| Riverside, California |
Frank Flowers, MD, Department Chair, Department of Family Medicine, Riverside Medical Center, Riverside, California
Walter Morgan, MD, Director of Residency Program, Riverside Medical Center, Riverside, California
Amanda Rosaasen, MD, Resident, Riverside Medical Center, Riverside, California
Glenn Thomazin, DO, Resident, Riverside Medical Center, Riverside, California
Others contacted for this profile:
- Robert D. Blair, Jr., Assistant Medical Group Administration, Riverside Medical Center, Riverside, California
- Sue Creed, CNM, MSN, Department of Obstetrics and Gynecology, Riverside Medical Center, Riverside, California
- Taylor Ferrell, Patient, Riverside Medical Center, Riverside, California
- James L. Gilkerson, Communications Manager, Riverside Medical Center, Riverside, California
- Jim Podzimek, RN, Director of Family Medicine Department, Riverside Medical Center, Riverside, California
Other Resources:
- www.kp.org
- Kaiser Permanente Inland Empire Focus, May 2004 - employee newsletter
- Kaiser Permanent National Diversity Council, A Provider's Handbook on Culturally Competent Care, Kaiser Permanente, 1999