Friday, May 05, 2006

The Mismanaged Initiation of the Kaiser Permanente Kidney Transplant Program: "Simply Out of Whack"

The Los Angeles Times published a series of articles (1-3) resulting from an investigation of how Kaiser Permanente mismanaged the initiation of its new kidney transplant program in northern California.

Kaiser Permanente is unusual among contemporary US managed care organizations in that it is not-for-profit and provides health services as well as simply financing and "managing" them. Heretofore, it has enjoyed a reputation as one of the best US managed care organizations. (Other problems at Kaiser Permanente were mentioned in this post, however, which noted allegations that the organization had posted real patient records on an unprotected web-site, and a dispute Kaiser had with a former employee who had revealed that Kaiser maintained this web-site.)

The background is that Kaiser Permanente used to contract with the University of California-San Francisco (UCSF) and the University of California -Davis (UCD) medical centers to perform kidney transplants on Kaiser patients. "In June, 2004, Kaiser informed kidney patients on the waiting lists at UC San Francisco and UC Davis that from then on their transplants would take place at Kaiser's hospital.... The first transplant was performed that October."

The LA Times charged -

  • Kaiser's paperwork snafus failed to give patients transferred to the Kaiser hospital credit for the time spent previously on waiting lists at other hospitals, thus dropping them to the bottom of transplant priority lists. "Kaiser took nearly a year to transfer the time [a particular patient] had spent on the waiting list at UC Davis." Also, "the same was true for hundreds of others at UC Davis and UC San Francisco who were stranded between programs for months by Kaiser's delays or paperwork snafus. Even today, UC San Francisco has about 220 Kaiser patients on its list whose time has not been properly transferred to Kaiser...."
  • Kaiser seems to have rejected an unusually high proportion of kidneys for transplant, thus delaying patients' surgeries although possibly increasing the chances of succesful transplants. "Through June 2005 Kaiser accepted only 16.7% of the kidney offers on behalf of its patients, far less than neighboring programs: ... UC San Francisco 24.1% in the same reporting period."
  • Kaiser failed to use a pool of high risk donors, which other programs have tapped with patients' consent. This further may have delayed surgery for patients willing to take such risks.
  • Because of bureaucratic problems, patients were denied the possibility of transplants with highly-matched cadaver kidneys.(2) "Kaiser never properly completed the paperwork to transfer the patients' cases to its program from UC San Francisco Medical Center.... At the same time, Kaiser would not authorize UC San Francisco to continue accepting kidneys and transplanting them into Kaiser patients...."
  • Kaiser failed to warn the United Network for Organ Sharing in advance of its intent to transfer patients to its own program. "The transition was further complicated by Kaiser's own paperwork, which was full of 'errors or inconsistencies'...." Furthermore, "hundreds of Kaiser patients were never told that their transfers had not been processed, in effect placing a new kidney out of reach...."(3)
  • The kidney transplant program had ongoing personnel issues. "Much of the core staff had never worked with transplant patients - or one another. In early 2005, the program's first transplant administrator left. Barely a year later, her replacement was terminated." One nephrologist "cleared out of his office and has not returned.... Officials say he is technically on leave." A physician who had complained about how the program was being run was put on leave after "feuding with [the] medical director...." The medical director has since been "relieved" of her administrative duties. She is now in fact the only nephrologist taking care of patients for the program. In summary, "since the program opened, 10 permanent employees have quit or been fired out of a staff of 22."
  • "The program has provided the Times with incomplete or misleading information." Kaiser denied until two days ago its instructions to UCSF not to transplant kidneys into patients whom Kaiser had failed to transfer to its own hospital's program. "But after being confronted with evidence to the contrary by the Times, the officials called back to say they could not stand by that position. One of Kaiser's own kidney specialists had confirmed that he directed UC San Francisco to turn down at least on e of the near-perfect-match kidneys, they acknowledged."
The Times got this comment from the ubiquitous Arthur Caplan of the University of Pennsylvania Center for Bioethics:

Something is simply out of whack with the health plan's priorities.
The San Francisco Chronicle also reported that the California Department of Managed Health Care is now investigating the Kaiser kidney transplant program.

It saddens me how Kaiser Permanente, which once seemed to be a model of how managed care could be accomplished, has fallen in this instance. I can only speculate whether constant pressure from less patient- and physician-centric competitors was partially responsible.

Perhaps it's time to rethink the whole managed care model that the US has so avidly embraced.

ADDENDUM (May 7, 2006) - Please note that an earlier version of this post included a badly written and possibly misleading summary of my earlier post on Kaiser. I have rewritten the summary above. I believe that this earlier post did correctly summarize the story as reported by an article in the San Francisco Chronicle in 2005. My apologies for writing this summary too quickly.

1. Kaiser Put Kidney Patients at Risk (May 3, 2006).
2. Kaiser Denied Transplants of Ideally Matched Kidneys (May 4, 2006).
3. Kaiser Slow to Transfer Patients (May 5, 2006)


Anonymous said...

I'm the employee referenced in the case where Kaiser posted patient information on the web. I did lose my job at Kaiser several years ago - because I tried to avoid being dragged into a scheme against another manager. It was a clear case of wrongful termination, and Kaiser HR had to destroy the email evidence to cover up for the manager. I found Kaiser's web site over a year and a half after losing my job. Though Kaiser attempted to frame me and implied heavily that since I had lost my job I must have stolen patient data (I didn't work at all with patients, by the way) - the DMHC eventually determined that Kaiser had posted the web site and it was up for around 5 years. Kaiser was fined $200,000 for this. Please stop helping to spread the rumor that I was fired in relation to the systems diagrams.

Roy M. Poses MD said...

The one sentence summary I had included of the earlier post was written too hastily, and hence was erroneous. I have rewritten it above. I apologize. The original post from 2005 I believe did accurately summarize the information reported by the San Francisco Chronicle about this case. I am puzzled by the last sentence, since I don't think I ever wrote anything about any "system diagrams," and don't know to which diagrams this refers.

Anonymous said...

Thank you for editing your post - though the Chronicle was a bad source for your original article. They took their cue from a scare-mongering segment on NBC news, and then they ignored my repeated requests for fact correction. One of the reporters I talked to (not the Chronicle) admitted that Kaiser's story was just easier to tell, while my story was "too complicated for our readers". In response to the general confusion, I finally put together a timeline here:

The timeline is backdated to 2003 to keep it separate from the rest of my blog.

The "Systems Diagrams" is my shorthand for the Kaiser web site that contained the patient information. While I have always described them that way, this didn't catch on because the press treated the web site like a big bundle of patient information. This was an extremely misleading representation: what Kaiser posted was a huge collection of technical diagrams and screenshots from systems that were then serving as the Northern CA EMR. In truth the list of Kaiser medical record numbers (the "patient information"), was very hard to find.

Anonymous said...

In the seventies, I worked for Ross-Loos. At the time nurses were leaving that HMO for one, they said, was far better. The HMO they spoke about was Kaiser Permanente. I, being a nurse, was tempted to switch, but later chose to leave Ross-Loos to work in a teaching hospital. Later, because of the great things I had heard about them, my husband and I selected their plan. We selected them 20 years ago. At first they fulfilled our expectations, but as time went by we have become thoroughly dissatisfied. Kaiser now shows the same symptoms Ross-Loos was suffering from before they went belly-up. It makes me sad that an organization which once had such a great reputation, has allowed that reputation to be tarnished by stupidity and greed.

Judith Nudelman said...

We had previously corresponded about how Kaiser settled two law suits in 2001: as telephone representatives (with high school educations) were given bonuses up to 10% of their salary if they kept patient phones calls short and only offered 15-30% of callers appointments, and the second allegation was that physicians were given incentives to withhold care. The cases are summarized in the archives of the Sacarmento Bee. It has been my experience, helping my family deal with Kaiser--even though my sister works for them, that their culture is based on cost savings, and they'll justify it with "evidence based" medicine when it suits them. Telephone receptionists may not get bonuses to keep patients off the phone and out of the centers, but the culture encourages limiting access to care.