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Pete Stark – Letter to

It is very important that everyone read all of this letter including the very revealing footnotes.  Please send a copy of this letter to Congressman Pete Stark to make sure that he sees it.  The web form to fill out and send him a letter for people all over this country is at the House Ways and Means Committee at: https://waysandmeans.house.gov/contact.asp
He will not respond if you send it to his local district office unless you reside in his area.

Charles Phillips, MD, FACEP
2216 E. Los Altos Avenue
Fresno, CA93710
CPhil49401@aol.com

June 26,2004

Congressman Peter Stark and
Other Members of the Subcommittee on Health
With in the House Committee on Ways and Means
239 Canon HOB, Washington, DC 20515

Dear Congressman Stark and other members of the Subcommittee on Health of the House Committee on Ways and Means:

Thank you for reading this letter from me, a physician in Central California spending half of my time trying to understand responsible health care policy. Please read it all as no short summary would do the HMO issues justice.

Introduction

As a Board Member of the Managed Care Reform Committee (MCRC) and one of its physician advisors, I would like to share with you that this last few weeks has seen several events in Washington, DC, that further threaten the health care of United States citizens in Health Maintenance Organizations (and even PPOs with HMO rules in the background). Through this communication I hope to add a little balanced information on HMOs to help develop a real debate on good and fair policies of government  I work as a volunteer on the MCRC.2

    First in line as a patient care loss event, the Supreme Court repeated unanimously their belief that the HMO Act of 1973 and its companion ERISA act a year later pre-empt the 67% of the citizens of this country – all those not tethered in some way to government – from being able to sue HMOs on a level legal field. The cases in point revolved around the withholding standard of care testing and treatment to two separate citizens in Texas.

    Yet all those people who are empowered to vote or decided on these issues – including all members of Congress and all of the Justices on the Supreme Court – can sue their HMOs and thus get a first tier of care. All such people should recuse themselves from deciding if the other 2/3rds of the country should have their right to sue or agree not to exercise their elite and self created rights until there is final equity in justice for all.

In fact, this right to sue for damage from health plans was available to all people until it was taken away by Congress through the HMO Act and its ERISA companion. The Chief Justice of the Supreme Court has explained a few years ago that the HMO construct is “the creature of Congress.” The courts can not undo the legislative misadventure much as they might wish to.

    So the buck lands nowhere else but on Capitol Hill. In fact, the whole campaign on patient safety was – according to the USA Today (and I concur) – developed as a managed care distraction to focus on the front line care givers and away from the rights of patients to sue fraudulent Plan decisions. Now, patients are a bit saturated with all the safety verbiage and are wondering once again about the right of HMOs withholding needed care, the most unsafe aspect of US medicine in the country. And patients want back the dignity of having a confrontation with a health plan in front of a jury of their peers for resolution and not to be forced into arbitration contracts).

    Second, and more specific to your committee, all of you heard a presentation by Andrew M. Wiesenthal, MD, on June 17, 2004 (Attachment #l) which asked the government to set Information Technology standards which might best fit Kaiser’s current efforts. This would over time have the value to Kaiser of about a billion dollars. He also hinted at the need for government assistance in Kaiser’s $3 billion IT investment, forgetting to mention that Kaiser’s profit last year of almost a billion – if repeated for the next few years  would pay for it just fine.

    The problem is that with this handout request through a Kaiser physician and senior, for  profit partners, there appeared to be alternate person able or willing to present the real  inner workings of Kaiser to give you another view to consider. If you proceed in  Kaiser’s path without opposing information, you will have guaranteed Kaiser an edge  over all competitors for the next thirty years – a huge gift.

    But Kaiser is a medical Enron that with all its venture investments and schemes. The  HMO runs completely opposite all of your efforts to separate patient care into clear units  without kickbacks in your Stark I and Stark II strategies. Kaiser’s exception to all the  rules makes the HMO – once again – the creatures of Congress. The exception concept is  that a large enough group of physicians could not have sufficient greed to each hold the  other to bottom line business practice where patients become “external customers” and  get less care. (Notice in Attachment #2 file attached Kaiser picture of patients as  “external customers.”) I wish to tell you that such widespread greed has become the  more traveled road.

    So, at least for the Congressional Record if not for your careful reading, let me share with  you the following thoughts to give you a chance for balanced, patient oriented thinking  that may help you with your upcoming decisions.  My comments will be divided into  two parts – 1) Kaiser Permanente as an organization, and 2) Dr. Wiesenthal’s particular  presentation and request for aid to Kaiser.

Kaiser Permanente-

    This prepaid health plan began with a physician named Sydney Garfield who decided after Los Angeles residency to try his practice of surgery outside of city and out in the desert along the path of the Los Angeles Aqueduct from the Colorado River. It was the Depression and there were not many jobs for average surgeons in the City of Angels.

    His desert hospital was called “The Contractor’s Hospital” – causing no confusion of whose primary interests he would really be serving. He quickly learned that getting prepaid was the only way to go and secured that system through businessmen in San Francisco organized through the Business Exchange to supervise the building of the aqueduct. His care was cheaper than sending patients all the way to Los Angeles. Often he drove his makeshift ambulance himself.

    Dr. Garfield pocketed $250,000 during four years of the depression in his personally owned, for profit, prepaid, health business. With the money he bought many apartment buildings in Los Angeles.  At the same time, his nurses often worked without pay. This is all clear in a book Kaiser Doctor Smilie wrote about Kaiser with help from many at Kaiser – a book (Can Physicians Manage the Quality and Costs of Health Care? The Story of the Permanente Medical Group) probably meant to be used internally to motivate new physicians. The book remains Kaiser’s only sanctioned, detailed history.

It will never be found in any of Kaiser’s 300 (?) patient education rooms.

    Henry Kaiser, Sr., teaming up with Bechtel and others, became involved in dam building and later ship building. These businessmen and also wished workers to get care in business friendly clinics and stared working with Dr. Garfield. Liberty ship building for England entrenched the Kaiser-Garfield team in the West Coast around the cities where the building occurred.

    And Kaiser is still 75% a California care system, having to retreat from many states – New York, Texas, Missouri, etc. It seems that New York patients really wanted a choice of doctors. Dallas did not like finding 20 wrongful death cases filed soon after Kaiser arrived.  The Mid-Atlantic beltway operation of Kaiser was simply another health plan bought as it moved out. This Kaiser unit has been a steady income loss to Kaiser. But it is a chance to make Congress believe that Kaiser is really national.

    “Dad” Bechtal taught Henry Kaiser from the beginning that the only good business systems create a 50-50 division of profit. 

And so as it was as Henry Kaiser, Sr. and Sydney Garfield, MD, split profits, settled in Lafayette, California, living nearby one another, and even marrying sisters.  And so it evolved some 60 years ago as the physician groups – having bought out Dr. Garfield – negotiated in a beach home owned by Henry Kaiser the internally key profit division of 50-50 between the Kaiser Hospitals and the for profit Permanente groups.

    This Tahoe Agreement, which may be read by your committee as needed (signature page enclosed as Attachment #3 with Sydney Garfield, MD, only willing to use his first name) set up the most lucrative physician reward system in the country – some 3,000 senior partners becoming rich taking care of those patients with few choices –
the elderly, those with moderate jobs, and the poor.

    On the enclosed Permanente Map (Attachment #4) – enhanced by me so as to readable by thoughtful people outside of Kaiser – you can see that the little figure of Lake Tahoe is prominent in the history of Kaiser Permanente. That building on the beach is not about a Kaiser Clinic but rather the location of a fundamental kickback scheme. An update national agreement in 1997 spelling out the same profit split and even more physician control – as evidenced by a photo op picture (Attachment #5) and article – has been referred to internally as Tahoe Two. It is all about renewing the kickback profit for doctors.

    As your Medicare investigators discovered in the mid 1980s but never emphasized to the people. Kaiser builds in its profit goals (3-5% of the budget – a budget now at about S22 billion a year) as the next year’s business plan is created jointly by the physicians and management. Administration and the physician leaders share the same 16th floor of the same building. Once the appropriate fee per patient per month is decided by the highest executive committee – the National Partnership Committee now co-chaired by Dr. Francis J. Crosson [and Mr. Halverson] – there is a pretense of an “arms’ length” contractual negotiation to solidify the amount.  The amount is about $70 per patient per month now.  This profit goal is reached by giving patients about half of the services that are expected by national standards societies – the American Heart Association, etc.

One of the key elements is blocking patients from hospital beds and kicking those that get in out early – each physician having daily to justify each day in the hospital to a lay business type person with no license. One patient died as such a verbal contest was occurring in the hospital hallway; the Kaiser physician – who was trying to do the right thing – decided to do no more hospital care thereafter.

    On the same Permanente Map please note that the physician patient relationship in the early part of the voyage to  investment capitol is later replaced by the Permanente Patient Relationship on the captains’ wheels. This allows the “wind” of the system to substitute the Group Ethic [read profit motive] for the Hippocratic Oath. In fact, the Kaiser physicians believe that all patients have some unwritten contracts with them – like spending less on the really sick patients so the premiums are kept down [or profits are kept up. They publish all this for internal motivation – agreement on the “genetic code” of Permanente Medicine – but it can be put together when needed. The articles in the Permanente Journals which are not emphasized on the front cover should be a must read for anyone in Kaiser. 

And this map should be studied daily by your staff.

    The goal of the Permanente fleet of for profit units are to keep to the two goals on the right side of your copy of the map – A) a “sustainable future” meaning the huge retirement monies hidden non-profit under the Kaiser Plan by a special IRS deal, and B) investment capitol from Silicon Valley [and New York City in the way of bonds] to have
the leading Information Technology system possible.  They do not mention all the many for profit ventures 50-50 between the Plan and the Physicians (the latter using the vehicle of the Permanente Federation and the Permanente Company or Permco) which allow Kaiser to often be on both sides of many business contracts.

Note that CareTouch was a company developed free within Kaiser using its computer systems (a $14 million value of technology) and then floated out as a private company with Dr. David McKinnon Lawrence still on board. I don’t think even Congress could ever map out Kaiser/Permanente full organizational chart (boards in charge), real operational organization (doctors in charge), profit investment systems, showing up on both sides of a contract (e.g. dialysis care), etc.

    Kaiser exists and flourishes because of media silence (ads on the radio and in newspapers), contributions to government, special treatment to government patients, toothless Department of Managed Health Care, sleeping regulators who like prime rib while reading contrived notebooks, and the huge help of the federal government.  To the federal government’s help there has been deferring Dr. Garfield from the draft in WWII so he could build his private, for profit clinics in free government buildings; then giving the same buildings to Henry Kaiser and Dr. Garfield almost free after the war; then giving huge grants to Kaiser for patient testing (1961); then allowing Kaiser to use high pricing on meds to get bloated Medicare financial credit; next letting Kaiser design the HMO Act of 1973 and the ERISA protection a year later; then further supplementing Kaiser as a federal HMO for more startup funds; then the special IRS ruling party “X” and party “Y” that lets physicians amass delayed, tax free fortunes; then exemptions from Stark I and II conflict of interest rules; then heavy input into the Clinton plan for health; lack of scrutiny of ads for Senior Advantage in the Medicare Plus Choice office; disinterest as Kaiser pretends that it was aligned with CDC guidelines on anthrax  AHCPR Grant HSO 6680 to help Kaiser write a book on how the sickest of patients have to manage their own care and now the invitation by your committee to perhaps have Kaiser set the standards for medical information systems. This is a win-win-lose – Kaiser wins big profits, government has chance to secretly ration care without yet sharing any blame, and an patients are abused by this terrible system of non-care – a business plan masquerading as health care. Kaiser is the leading cause in this country of senior abuse.

Dr. Wiesenthal’s Presentation to You – June 17,2004 (attached)
Here are my comments about this HMO7 infommercial: 1. Dr. Andrew Wiesenthal presented to you that Kaiser Permanente uses its information technology to help patients and physicians access clinical information to further patient care; what he did not explain is that one of the main purposes of the computer is to monitor every physician on every possible patient care activity – prescriptions, specialty referrals, pharmacy costs, lab costs, out of system referrals, etc – so that each MD will be judged in all areas as a “business center” – particularly when being observed for the first two years before ascending to Junior Partner and for profit level:8 2. The text suggests a fairly smooth progression from his IT work in Colorado, then the CIS system under Dr. Lawrence, and then the replacement with tlie EPIC/Cisco system brought in by Mr. Halverson; rather the truth is:


A. one day Kaiser Oakland grabbed the mainframe computer in Kaiser Colorado and took it back to California because Dr. Wiesenthal and others in the mile high city wanted to stay with their regional system and Dr. Lawrence wanted to show his central power as Kaiser’s chief;

“Kaiser, five years and some $2 billion in IT investments later, is still trying to make progress, and the cultural uproar triggered by Lawrence’s no-holds-barred ultimatum still rankles. For some, Lawrence’s decision was akin to a declaration of war. “Up until the time of his decision, ” says Henry Neidermeier, a Kaiser IT executive in charge of Web development, “Kaiser was run as a collegial organization, not like a corporation. Physicians had been making all the decisions. ” Lawrence, a former physician himself, says it was the toughest management decision of his career. “It was a unilateral action, ” he says. “I was deeply criticized and resented. I had several very, very uncomfortable conversations with physician leaders. “Lawrence says he remembers more than one shouting match with physicians hehad known for years, including several calls by some physician’s for his ouster.Andy Wiesenthal, a doctor in Kaiser’s Colorado region recalls: “There was open dissent … It was a very difficult time. ” Almost overnight, Wiesenthal, -who wascritical of Lawrence’s mandate at first, suddenly found he no longer had an IT department to generate his analytical reports – it had been dismantled and most ofthe IT workers were relocated to Kaiser operations in California.  “All the peoplewere gone. The rooms were empty. The mainframe was removed.” Wiesenthalsays.  “The message was impossible to miss. “

Case Study: Kaiser Permanente by Eric W. Pfeiffer

– cioinsight.com 4/15/2002

Note that $2 billion was wasted as this 2002 CIS system was later scrapped; the new $3 billion figure includes some of the past wasted money.


  B. the physicians reacted by requiring a new partnership agreement in which there are no such surprise moves, a non-physician would be the next head of Kaiser, and the 50-50 power relationship would prevail at the top
executive committee. Dr. Crosson being the co-chair [the other co-chair is never mentioned but is most likely Mr. Halverson himself];

C. switching to the EPIC/Cisco’s system involved going to a small player in the field and allowing Mr. Halverson to dump most of Dr. Lawrence’s top administration; the real question is whether or not the many venture systems at Kaiser are caught up in the EPIC contract whereby promoting this system makes more kickback money for Kaiser’s many venture projects9 (my estimated chance of this is 99%10;

D. Kaiser has a “license” from EPIC “to use and deploy EPIC’S suite of software”; its attempt to create the brand name “KP HealthConnect” is for the purpose of trying to make this IT system look like it is an in house creation to the public and to you; E. Adam Kiefert changed employment from Epic Systems Corp. in Madison, Wisc. to work with Kaiser IT in Colorado Kaiser – “I’m the only person here who knows the system, which puts me at a great advantage”; so this is not about a smooth expansion of the original system; (from Biomedical Engineering Alumni Profiles –

Adam Kiefert – Class of 99 – MSOE – perhaps four years out of college, he was one year ago the lead person in Kaiser Colorado IT Department11.

F. Kaiser is basically bragging aboat a system it has had in some places aboutone year after two other, different IT systems failed to do the job; setting government standards around them would not make sense;

3. In the presentation to you. Dr. Wiesenthal avoided repeating the lie that Kaiser Permanente is “non-profit”; but outside of the beltway, this phrase and illusion is passed on to the public in a thousand ways – news releases, newspaper ads, radio ads, etc. (even on the Kaiser reference in Google);

4. Only the Washington DC Kaiser unit (mid-Atlantic) tells the truth in its ads that only the Kaiser “Plan” is non profit, since then Permanente physicians are for profit; so Kaiser is careful where you can listen and watch but cavalier where you cannot keep track of what they are saying to the nation.

5. In Kaiser’s bond release this Spring of 2004 aimed at investors in New York, it was clear that Kaiser had “more than 11,000 physicians”; for you they rounder the number up to ” 12,000″ just to try to look bigger as information in this HMO is made to be spun;

6. Dr. Wiesenthal suggested that through the Public Health Grant of 1961 that Kaiser had “internists armed with computer print-outs of pertinent medical data”; I am quite sure that this was not true and the Cleveland Clinic and many others would dispute this; (I visited Kaiser in San Francisco in 1967 during a search for internship and saw the lab printout which was long but not unique12.

7.  With the Public Health seed money for testing withdrawn long ago, Kaiser now does the least testing possible and even publishes articles to the same effect in the Permanente Journal; so the real goal is now reversed – full chemistry panels looking to uncover disease are rare – but the organization would still like the multiphasic testing mystique to be attached to the Permanente brand name.

8.  I review new Kaiser patient records about once a month with patients or surviving relatives permission; I have yet to see an easy to read, computer printout of information;

9.  While Kaiser Colorado is heralded in this report to your committee as wanting information to flow well, internally the physicians have been counseled one on one not to ask for the old chart of patients so often.

10. Next Dr. Wiesenthal quotes an anonymous Kaiser physician in an anonymous location (? real or not) being able to complete a consult on the same day; I would challenge Kaiser to come up with the author, (it sounds more like a chapter theme from Dr. Lawrence’s book from CHAOS to CARE using fictional characters; the book was written after Helen Hunt commented in a movie about HMO failures and got audiences clapping around the nation in otherwise before and quiet theaters);

11. Contrast this to the reality of a Washington D.C. patient holding a job who came into Kaiser on January of one recent year saying he had Hepatitis C and needed a Gl visit only to have no Gl appointment at all with liver failure death coming 8 months later, speedy consults are not the internal reality of Kaiser computers or not;

12. An attached cartoon (Attachment #5) – a sample of Kaiser’s twisted humor – shows the real attitude that rapid care costs money – don’t hire enough surgeons despite patient backups in surgery; in one location in Northern California Kaiser was caught giving out bonuses to Call Center employees who could handle a patient problem on the phone without giving away a physician visit time;

13.  Then Dr. Wiesenthal promotes the idea of the computer as “on-line, real-time support information” for physicians; actually these are popups on the computer which the physician must follow or explain why not – an example of the illegal practice of medicine by a corporation like an unlicensed, for profit Permanente group;

14. The pop-ups are not state of the art suggestions but ratlier crude business suggestions like using medications from the 1970s and 1980s – Tolinase for diabetes, barbituates for depression, etc.; these type of suggestions are also in pocket handouts given to all the physicians (surprise check any Kaiser white coat or nearest drawer);

15. As Kaiser is now trying to avoid putting diagnoses on patients so they cannot check them on the Internet, the “after-visit summary” will not be thorough to the care;

16. “Team care will be more patient centered” comes from the decision in 1997 within the Recovery Plan for 2001 to increase membership, retire physicians, and substitute nurses, pharmacists, dieticians, and others for MDs; physicians were to try to phone patients and have them write letters back15 to keep the clinics less crowded – all being separating the physician from being the personal friend they try to advertise on the radio.

17. So noting that visits to the MD go down is not about electronic care but a planned reduction in physician-patient time; this did result in getting profits back up – nearly one billion dollars last year (half to the physicians).

18. “Finally, clinical research to support evidence-based care will be greatly enhanced” is mentioned, but Kaiser is the HMO that most hides its supposed “evidence-based” material from the world; on the Internet it can only be found on the Kaiser Papers Website, one run by a Vickie Travis with our support of materials and totally unauthorized by Kaiser,

19. The Clinical Practice Guidelines pretend to be a reflection of national standards but are not; for example. Kaiser will not search its obese patients for diabetes despite the American Diabetes Association pointing out the obvious – that this is a good group to screen for  diabetes.

20. Dr. Garfield taught – opposite to all the Kaiser ads – that Kaiser dispenses wellness not sickness care; together with his “economy of shortages,”17 often no care occurs at all.

21. On page 4 of his report to your committee, Dr. Wiesenthal completely avoids the fact that Kaiser scraped its internal IT program in 2003 and went with an entirely new, outside brand from Wisconsin for which it had no training; ratlier he states “This explains why we have worked so hard to help the industry develop the tools that are the foundation of many systems now in use or development”

22. The goal of his presentation finally becomes clear -it is a request for more money from the federal government – the “provision of targeted financial support for public- private partnerships”; you might as well have McDonalds ask to be a central government partner in developing Big Mac standards to be used for all hamburgers.

23. No doubt Kaiser and the VA would like to get many dividends from their $2 billion each investment in IT – two organizations each of about the same size budget; private physicians would be left behind as well as other health plan competitors;

24. Your committee might do well to study the death of a Ven-Cor patient who was getting tired with and needed oxygen for the night for safety – and such was ordered – but with all the steps needed to execute this order of simple care through the computer, the patient missed the treatment and died a suffocating death; computers have not replaced people particularly in systems where the money spent on IT is taken from other areas that require a lowering down the job training of the front line participant

25. Dr. Weisenthal continues: “We are convinced that widespread adoption of health care information technology like KP HealthConnect” [really licensed EPIC] “is essential for sustained quality improvement” is a statement that is entirely self serving and should not be accepted for one moment until the web of financial relationships and for profit ventures are made transparent for the first time in Kaiser’s history; otherwise it is simply a welfare handout for the rich (check the million dollar retirement packages of the senior partners).

26. “The Leapfrog Group has been a leader in the introduction of payment-quality standards, especially for hospitals” obscures the fact that Kaiser has also developed self serving “quality” standards; these efforts hide the fact tliat Kaiser’s real focus is to kick patients out of hospitals before they are well or even worse commit them to rogue hospice units with too much uncharted morphine in caregiver pockets.

27. “Ultimately, for payment incentives to have real influence on quality, they should be directly tied to the care delivered during a specific time period,” and Kaiser with its benchmarking tracking of physicians will be the only one ready to supply the demonstration projects; the government will forget in the process that the Kaiser physicians already have dazzling incentives to withhold care.

28. Kaiser’s good score on a California survey of heart attack ontcomes, as an example, came from convincing 25% of the patients at the door that they would not like to have any care at all making them DNRs – within the survey the equivalent of dead at the scene; so Kaiser statistics are as bad as Mark Twain predicted of all statistics.

29. Kaiser’s view of itself- expressed to you as supposedly an organization sharing good ideas – should be asked by you to publish all of their Clinical Practice Guidelines for physicians (outpatient) and the parallel Pathways for physicians (inpatient) each for the first time; instead, they guard these items and the huge profit systems as if it was gold buried in Fort Knox not even the AMA getting to peek at them;

30. Medicare and Medicaid made Ross Perot a very rich man by subcontracting data techniques which could then be used privately by the same contractor. Kaiser would not mind duplicating that path with its IT.

31. Both the VA and Kaiser make their patients split medications into pieces of uneven fragments just to save money even though the patient ends up with a 40% swing in dose (see Timmis v. Kaiser case now in appeals court); many Kaiser patients start with big pieces and work their way down to dust – does this sound like a quality outfit to you?

32. Rather than following Dr. Wiesenthal’s congratulating the committee on this “timely and important hearing,” I would rather remind the committee that if greed were to be removed from health care that there would be enough money to provide the right treatments no exception for organizational size; first make greed transparent, then hold hearings on IT standards.

33. And I would ask each of you as former patients somewhere in the past if you did notget the best care of your life when you could truly go to the physician of your choice andcultivate the patient-physician relationship promoted and promised by Hippocrates as anoath and a covenant – the whole meaning of the white coat; and if so, do not presume that forcing all private physicians to spend tight dollars on system electronics will result in even the slightest improvement in care.

Conclusion
Every time Kaiser Permanente representatives make a presentation to Congress, aminority report should be allowed so it is clear that free thought is possible. Hearings should not be used as preparations for enabling and assisting HMOs, as has been done so many times in the past. If Congress cannot regulate HMOs, at least let others through letters like this make them transparent. The public expects no less. Dr. David McKinnon Lawrence – former Kaiser CEO who now exports Kaiser ideas (of empty hospitals) to England – and I were both premeds on the Amherst College campus just one year apart. But we have taken different paths and have an entirely different vision of medicine and the covenant of good care.

Dr. Lawrence believes that the Marcus Welby, MD, TV show was not helpful to patients and only described the “lone eagle” practitioner who has become extinct in this new era of medical economics. As a small town physician with a sound education, board certification, and 35 years of real medical practice, I would encourage you to let both eagles with patient compassion and accountants still wearing MD white coats compete so patient advocacy will not be banished from this planet
  In the final analysis you need to understand the Group Ethic versus the Hippocratic Ethic and know which one you are really funding. Your own personal health depends upon it as well as the health of all whom you represent.

Sincerely, Charles Phillips. MD. FACEP

  1.   I am a near constant participant in the Dialogue chat group of the Health Administration Responsibility Projectrun by Harvey Frey, MD, PhD, and JD.   (HARP.org)
  2. I have worked 90% in the US (California, Nevada, Utah, Minnesota, and Guam but have also seenpatients in Canada, New Zealand, Thailand, and Saudi Arabia, in the latter situation once being on call tothe King in case of emergencies.  I have also visited health care delivery in Japan (riding out withambulances) and health care teaching in the Philippines.

3. One published, internal strategy of Kaiser is to leave a copy of a Permanente Journal lying around your Congressional office to give the illusion that is a nationally accepted journal of medicine and research which it isn’t; physicians realize it is more of an internal communication device.

4. Kaiser headquarters in Oakland taxed its Missouri Permanente physician group $3,000,000 a year to artificially support the mid-Atlantic unit. When the Missouri operation closed as a failure, the physicians suing Kaiser brought that up. Another issue was loss of profit equity.

5. Kaiser taught its clinics that Anthrax presents with shortness of breath and a low oxygen reading; the truthis that Anthrax goes to the middle of the chest and creates sudden, life threatening problems – and organisnthat makes elephants drop in shock just before death. Only a chest CT can screen for Anthrax as the CDCknows. Kaiser did not learn when it cost the life of a postman working on mail on the way to Congress; hecame in asking to be screened for Anthrax and went home to die. Don’t go to Kaiser if you think you have Anthrax.

6. Kaiser Permanente LIVING A HEALTHY LIFE WITH CHRONIC CONDITIONS – Second Edition -Self Management of Heart Disease, Fatigue, Arthritis, Worry, Diabetes, Frustration, Asthma, Pain,Emphysema, and Others, lf “frustration” is a disease, then patients who ask for full service care – as theads promise – will be considered ill; Kaiser undermines self esteem when someone fails to be Kaiserizedinto accepting substandard service.  The book can only be loaned to patients by Kaiser – like the one Ihave has a library card type return policy. Patients get two weeks to learn how to manage their diabetes.

7. Kaiser hates to be reminded it is an HMO, since the Kaiser Family Foundation has through its paid time for surveys in the Washington Post proven HMOs to be near to hated. Instead, the goal is to create the Permanente physicians as the Brand Product – highly selected, good listeners, the hands of healing, and rewarded only by pure salary. One ad firm alone is getting $40,000,000 this year to promote this concept, one far from the truth.

8. The physicians learn once a month in peer group meetings how they stack up as a business unit with the hope that for profit peer pressure will Kaiserize them into cooperating. Those failing to abandon their advocacy oath next get the 1:1 private warning – shape up or ship out. Those still failing are told that they are not manage care compatible – as if there is another legitimate form of medicine. The American College of Emergency Physicians has given clear expression to the idea that there is only one form of medicine.

9. Most of these ventures also are 50% owned by the plan and 50% by the for profit physicians; the IRS does not care if a non-profit plan is 49% for profit.

10. Kaiser physicians often balk lately at filling out the California Medical license renewal at Item G – “I certify under penalty of perjury that I have disclosed on this renewal application form (see reverse for space) the names of those health-related facilities in which I or my family have a financial interest or I certify under penalty of perjury I have no financial interest to disclose.”  An audit would occur if the Board was not so connected to Kaiser – for example, a disproportional number of its medical “experts.”

11. By the way if you call for emergency help through Kaiser m Denver your call will be handled just out of Madison Wisconsin by dispatchers with little training but connected to Kaiser through another profit contract – See USA Today story.

12. Kaiser would have paid me more than other intemships, but I wanted a real education through the San Francisco General Hospital with university teaches still on oath target. Kaiser’s letter to me this week inviting me back to a high salary will also be unanswered, I am not for sale.

13. I am also sure that Kaiser has a difficult-to-read keystroke for records going to patients through the Kaiser legal office; this is designed to frustrate outside medical expert opinion.

14. This book was written on a prolonged retreat outside as Dr. Lawrence became more advisory in his final year to the incoming CEO. The book demonized the average, private pediatrician. Book sales have not been brisk.

15. One Kaiser patient tried to write her physician about he allergies, but he kept giving her the wrong medications and not seeing her, the Kaiser pharmacist spent most visits flying to talk her out of prilosec.

16. The Managed Care subcommittee of the American Diabetes Association (ADA) waters down some of the recommendations; Kaiser really wrecks them internally. But the public is told that Kaiser is busy partnering with the ADA so all of the patients are fooled all of the time.

17. See Dr. Smilie’s book for the time and place of this teaching moment

18. The richest man in Thailand did much the same – helped developed cable TV and then bought up all the franchises with his insider knowledge; his name is Thankin and may be the current prime minister enriched by public-private partnerships that lead to enormous greed and a higher expense for each Thai to use.

19. I did work at a VA within the past few years. For all the emphasis on safety, the light bulb was off where the physicians select the night medications. And the x-ray tech was forgetting to collimate (protect) the patient from excess radiation.

20 Audrey Timmis was my patient and is still my friend. She was and is lead plaintiff on this case.  Why wreck the medications of a patient already on oxygen? Split fragments would fly across the room when her husband tried to spirit one hundred into two hundred doses of blood pressure pills. The suit is lead by the Trial Lawyers for Public Justice. I am a volunteer. Kaiser has video taped me for 12 hours on the case so far.

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