Broccoli branding, 23-hour clinics, and the bone phone: new lessons from Kaiser Permanente

On 22 July, The Nuffield Trust held the first in our series of seminars focussing on ‘High Value Health Care’, in partnership with the Royal College of Physicians and the Cambridge Health Network.

Before the seminar began I heard a few mutterings from audience members about how comparisons between Kaiser Permanente and the NHS are so well known that they’re becoming a bit trite.  
 
However, by the end of Bernard Tyson and Jed Weissberg’s presentations, nobody could be in doubt that the NHS still has many useful lessons to learn from Kaiser – not least in terms of their IT, arduous target regime, and new hospital avoidance measures.
 
Using the tactics described below, Kaiser is achieving cost containment of under 5 per cent inflation a year (considerably lower than the US average), whilst maintaining a 4 per cent profit margin. Despite this, Kaiser’s philosophy shines through: aiming for the highest quality health care at a reasonable price, fully integrated across a range of dimensions, and caring not only for Kaiser’s members but also for their communities.

Information technology
Like the Veterans’ Health Administration, Kaiser is convinced that its success depends centrally on having a single electronic medical record (EMR).  Kaiser has invested heavily in its EMR, called KP Health Connect – spending $5bn in the last five years alone.  However, the real cost of an EMR is not the software itself but rather the training, support and hardware.  All of these are far cheaper for Kaiser because it has one IT system spanning the entire organisation, including primary and secondary care.  
 
KP Health Connect is extremely reliable (it's available 99.9997 per cent of the time – “the 5 nines”) and patients can use it via the web to book appointments, read a version of their medical notes, obtain test results, and correspond with their clinicians.  Twenty-five per cent of consultations within Kaiser now occur via email (always at the request of the patient), which is highly cost-effective because email consultations cost only a tenth of a traditional consultation.
 
Targets
Kaiser sets extremely stringent targets.  Many of these, such as infection control, accept zero tolerance – a philosophy derived from the airline industry.  Indeed, Kaiser has an airline pilot serving on its Board.
 
Kaiser’s hospitals are monitored against severe targets on a dashboard showing each hospital’s performance on quality, affordability, effectiveness, safety, eco-friendliness and staff morale.
 
The upshot is that Kaiser is now ranked top on eleven separate HEDIS quality measurements nationwide.  In order to “keep the pressure on”, senior managers do not waste time debating what Kaiser’s targets should be—all that matters is whether and where there is capacity for improvement.
 
Integration
According to Tyson, integration has led to a cost advantage of 15 per cent over Kaiser’s competitors.
 
Integration could not have been achieved without the single EMR.  Because this spans primary and secondary care, the burden of delivering chronic care can be spread across the system.  For example, if a patient with diabetes presents to a dermatology clinic, the dermatologist will be alerted by the EMR if a blood test (such as HbA1c) is overdue, and can arrange for the test to be done then and there.
 
Hospital avoidance
The cost of hospitalisation means Kaiser does everything in its power to avoid unnecessary admissions.  
 
"Physician triage” at the front door of the emergency department means many patients can be treated without ever setting foot in the hospital. 
 
A senior Kaiser physician has the final say over which patients will be admitted. Patients who might be discharged within 24 hours are not admitted straight away but instead managed in a "23-hour clinic".  Four to twelve hours after arrival, a decision is made either to keep the patient in the clinic (for up to a maximum of 23 hours) or to admit them to hospital. 
 
Specialist hotline
For many years, Kaiser has operated a "bone phone" where primary care physicians can speak directly to a duty orthopaedic surgeon, and also a "uro-phone" for urology.  All specialties are now required to operate this type of hotline, allowing primary care physicians to obtain a specialist opinion while the patient is still there.
 
Branding
Recent surveys showed that some patients saw Kaiser as a large, faceless organisation.  In response, Kaiser refocused its customer services so that members feel "cared for" and spent $40m on rebranding.  See for example these adverts about Kaiser’s values (“we stand for broccoli”), healthy livingand health ageing.