Since we love to gripe about healthcare providers, but rarely get a chance to talk with them frankly, I was excited to recently run into some executives from Kaiser Permanente (KP) at a healthcare blogging event. Love 'em or hate 'em, Kaiser is America's leading integrated health care organization with a unique nonprofit business model (and also those cool "your-couch-is-a-carb" / Thrive commercials).
They are very interested in Social Media, so it didn't take too much coercion to get them to agree to a DiabetesMine.com interview with one of their most articulate (and approachable) leaders. Dr. Michael Mustille serves as "Associate Executive Director, External Relations." A very big PR title. But Dr. Mustille is also an occupational medicine physician with 33 years' experience and former director of the South San Francisco KP medical center. He now sits on the executive committee of the Permanente Federation, the organization's medical arm, and is personally involved in quite an array of medical quality initiatives.
Oh, the irony! Of course I conducted this interview before last week's allegations of mismanagement and medical misconduct hit the fan.
Anyhoo, here's what Dr. Mustille had to say about what he believes makes Kaiser effective and how this affects people with diabetes.
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DM) Kaiser has been pioneering in best practices for chronic disease management, even launching the subsidiary KP Healthy Solutions to license out their expertise. So what does KP actually do so well here -- for diabetes patients in particular?
MM) Why is Kaiser is such a leader in healthcare? I'd say it's all about Quality of Care. We've exhibited this consistently, and over the past decades two things stand out: our treatment of chronic conditions and our "health & wellness" push for the best possible prevention and screening.
This is actually substantiated using standardized quality performance measures, including those from the NCQA, which monitors quality insurance and certifies health plans/HMOs across the country. They use a standardized data set, and a publicly available rating methodology. (You can look up report cards on any HMO in the US.) Kaiser is at or near the top across the country.
These standards include, for example, a bundle of diabetes-related measures for patients: did you get your A1c tested? Your lipids tested? Your microalbumin measured? We do sometimes survey patients, but mainly we track the quality of care received from our records, including claims data and chart reviews.
Of course, measuring in these ways isn't the same as making people healthy in their day-to-day lives. For that, we need a coordinated program of actions/treatments that help get patients where they need to be health-wise — in this case, whether they have pre-diabetes, full diabetes, or complications of diabetes have already set in.
DM) How easy is it for diabetes patients with Kaiser to get their "diabetes care team" — endocrinologist, CDE, nutritionist, podiatrist, etc. — to actually communicate and work together?
MM) One big advantage is shared medical records. At Kaiser, all those people work in the same organization, usually at the same location. In a less coordinated system, your providers are across town and each has his or her own medical records — which are incomplete, because they only show the care you received at that office. KP providers work shoulder-to-shoulder with the same records, measuring real outcomes.
We treat 277,000 patients across the country with diabetes (out of 8.5 million KP members total). We know their A1c, whether have seen the doctor or where in the hospital recently, and whether they've filled their diabetes prescriptions. We can tell who they are, where they are, and what level of control they have, so we really know what works in terms of team care.
We're making a real effort right now to further advance health information technology with a new suite of software applications called KP HealthConnect (Editor's note: which has also come under scrutiny). Everything important for each member is recorded electronically, including visits, lab results, prescriptions, etc.— no more paper medical records. The information can be shared with any KP provider anywhere.
We'd also like to see interoperability outside of the KP system, so emergency teams and other important providers have some way to retrieve and transmit critical patient data. We're participating in a national effort to foster the Interoperability of Medical Records.
DM) Isn't Kaiser helping to establish standards for transfer of information from all different kinds of medical monitoring systems (the Continua Health Alliance)? What are some of the roadblocks or hot buttons there?
MM) Yes, this is a different issue, which is how to make medical devices "talk to each other." Kaiser is a charter member of the Continua standards committee. The focus is on Home Monitoring Devices — scales, glucose monitoring, blood pressure devices and so on — would connect ideally with each other to some extent and also to a database at your provider's site.
We're great at designing systems that sound powerful, but are siloed, meaning they work great only in the scope of their own needs, but don't contribute to your overall health care. Lots of new devices beg the question: Is this really helpful? Or just confusing, and possibly even dangerous?
These systems are very new, and people tend to lump a number of different monitoring technologies together. What exactly will their value be, and for whom? These questions need to be answered by doing some studies.
DM) What about moving to continuous glucose monitoring (CGM) as the standard of diabetes care? Where does Kaiser stand on this issue?
MM) One of the nice things about practicing medicine in KP is that if you have a great idea on how to help people, you can go ahead and try it. A few of our endocrinologists in Southern California identified CGM technology early on and decided to try it. They experimented with patients using Minimed's model and found it very useful for hypoglycemic unawareness. But most Type 2 diabetics can do very well without such a system.
DM) So are patients encouraged and/or supported to try the latest cutting-edge treatments?
MM) In Kaiser, a CGM device would be covered if the patient cannot achieve good glucose control even after exhausting all the other efforts. That is, we take a step-wise (or evidence-based) approach to using new therapies. We have quidelines for what treatments are appropriate to start with, and what's the next step and the next step after that.
We don't consider these things insurance decisions. These are medical decisions at KP.
It really is a matter of the individual and their physician making the decision; if they believe that current therapy isn't working well, they can decide to move on to the next step.
DM) How is your approach particularly progressive or different from what other healthcare organizations are doing?
MM) We actually have evidence that diabetes patients at KP are doing better than elsewhere. For one thing, we have an innovative way of evaluating actual costs. We've created an analytical engine using financial and clinical information to estimate the costs of covering certain populations. For example, we could take all the available information for people who work in a rubber plant in Des Moines, Iowa, and estimate costs for that population.
With this predictive model, we can calculate outcomes 10 years from now if we change the peoples' treatment, i.e. if we implement a nutrition plan or put them on certain medications, what's the likely impact on their health complications? This is really significant data, because we can save thousands of dollars and prevent hundreds of heart attacks!
With regard to diabetes care, we can see that there's generally a return on investment (ROI) of 2 or 3 dollars on every dollar put in. That's strong financial evidence that proactive diabetes treatment is a huge cost savings for providers in the long run. For employers, it also means less absenteeism, no excess money wasted in redundant treatments, and so forth.
DM) How does all this play out from the patient's perspective?
MM) We offer our expertise via web-based and phone coaching, in which patients have direct contact with health coaches who help them develop plans for their individual needs. This is not just for chronic conditions, but also for nutrition, exercise, stress reduction, end-of-life care, and much more. This is the service that KP Healthy Solutions helps offer to organizations outside of Kaiser.
We've had the biggest impact (cost savings and outcomes) with chronic conditions like diabetes, asthma, coronary artery disease, heart failure, and depression.
Depression is unbelievably relevant. We've learned that, for example, a diabetic member generally spends 4x as many days in the hospital than an average member. With depression and diabetes, the member spends 8x as many days in the hospital. So one of the first things we do is screen patients for depression. We also train our care teams on how to identify motivational factors, and we're making counseling part of the treatment plan.
DM) What about early intervention and pre-diabetes care?
MM) We have guidelines for that, 220 pages of them! Seriously, if a patient has a family history of diabetes or other markers, then we do proactive screening. We also know you can't apply this kind of care as a cookie cutter approach; it has to be tailored to the individual.
Also, we have a new A-L-L initiative to incorporate cardiovascular risk management into diabetes care. This says BG control is important, but lipid control is also crucial. Cardiovasulcar complications related to lipid abnormalities are one of the biggest killers of diabetics. A combo of medicines can really help: Aspirin, Lovastatin, Lisinopril.
We're targeting every diabetic over 55 and those with other complications, such as high blood pressure or coronary artery disease, and putting them on these three meds, which are proven to reduce cardiovascular damage by 20-30%. We see tremendous impact already, because the complications of high BG show up much later, but the cardiovascular problems (heart attack, stroke) typically show up within a couple of years.
Beyond that, we also have an excellent proactive system of patient reminders for your next pap smear, next mammogram, and so on.
DM) Kaiser got pretty beat up recently in the kidney transplant scandal. How is it working to restore patients' faith in its care?
MM) I must admit that we didn't handle that well. There's some irony in the sense that the actual transplant care was good, but we blew it with the administrative part. We failed to get patients transferred onto the new waiting list in order of their existing seniority. So people ended up in limbo on the recipient list.
What are we doing about it? Phasing out the transplant program. We brought the program in-house because we thought we could do better job. But we're admitting defeat in this area.
What we're realizing is that we can't handle this kind of program without a major administrative overhaul. So we're shutting that program down until we're sure can we do it right. We're not giving up on kidney care, but going back to using outside contracted surgeons to conduct the transplants, at UC Davis and UCSF (which is how we did it previously).
DM) Finally, Kaiser's unique capitation system (members pay a fixed amount per covered "head" per month) makes some people believe they are barred from using Kaiser unless their employer is contracted with the organization. What's the opportunity for people already diagnosed with diabetes to join Kaiser if they wish?
MM) Most of the people who get into KP do come in as part of an employee group — especially if they have a pre-existing chronic condition, because as part of a group, they don't need medical screening to join.
If you apply as an individual, you do have to go through screening. And you could be refused or have limitations placed on your coverage, meaning you may have to pay for some treatments out of your own pocket. And to be honest, some people probably do get rejected out of hand. That's a good reason why most people look to work for a company offering good health insurance benefits.
DM) Dr. Mustille, what's your message to the diabetes community?
MM) I just think that Kaiser is a very good place for people with diabetes. A coordinated, organized system is the best way to care for a complicated condition like this. So I would say, if you have access to Kaiser, you should take advantage of it.
You won't hear that from a lot of other health plans — asking potentially expensive members to join... but I would say we do a good job with diabetes, and people should take advantage of it if they can!