Populations that are targeted
The primary populations targeted by Kaiser Permanente are employees and families with no specific disease or condition being targeted; rather, Kaiser provides a broad array of medical services that are customized based on the needs of a particular client. For example, the health plans provided for employees by a company utilizing the services of Kaiser may be broader as compared to the plans for families that have specific hereditary conditions (i.e. a history of heart disease, cancer, etc.) (Strandberg-Larsen et al. 2012). The primary population targeted by Kaiser within California is usually 23 to 55-year-olds with its secondary client base consisting of individuals 18 and below and 60 and above (Strandberg-Larsen et al. 2012).
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Participating payers under Kaiser Permanente consist of Medicare, individual payments or prior contracts with local businesses. Due to the size and number of facilities that Kaiser has, this enables the company to enter into different types of specialized payment contracts as compared to other care providers. This means that Kaiser is not limited to Medicare insurance, rather, it allows individuals and businesses to custom design their payment plans based on their needs (Strandberg-Larsen et al. 2012). In fact, a person can apply for a specialized insurance plan online through Kaiser via their website and get medical insurance within a few minutes.
Type of Insurance Product
It is interesting to note that Kaiser Permanente provides both HMO and PPO plans on a per-client or a per business basis. What must be understood is that Kaiser is one of the largest health care service providers in the world with a network of 37 medical centers and 14,600 active physicians (Strandberg-Larsen et al., 2010). As a result, it can leverage its resources at a far more effective rate as compared to other healthcare service providers. As such, the type and scale of coverage depends on the needs of an individual or business in question. On average, businesses normally opt to have a broad HMO for their employees that allow for low to mid-level deductions on consultations and surgeries or even cost-free services (Strandberg-Larsen et al., 2010). Though such plans do have a set limit and are often lacking when it comes to more specialized needs and services. On the other hand, PPOs are usually utilized by families or individuals that require more specialized services or need to be able to visit any doctor they choose.
Since Kaiser Permanente is an integrated managed care consortium, this means that it has its own medical care facilities and subsidiaries. Its health care providers primarily consist of its various foundation hospitals and as well as its autonomous medical groups located in various states in the U.S. These establishments are primarily located in Northern and Southern California, Colorado, Georgia, Hawaii, Washington D.C. Maryland, Virginia, Oregon and Ohio. All in all, Kaiser has roughly 8.9 health plan members that are spread across the various states that have just been mentioned.
How are the participating providers reimbursed?
Due to its nature as an integrated managed care consortium, reimbursement within the participating providers of Kaiser Permanente is done through its integrated online system which tracks and records patient visits (Paige et al. 2012). What must be understood is that under an integrated managed care consortium, the same problems related to reimbursement are minimized since the provider of the plan and the owner of the medical center are a single entity. This enables a more seamless payment process as soon as a patient gives their insurance information to the front desk (Paige et al. 2012).
It is interesting to note that one of the most progressive aspects of the Kaiser PCMH program is that it is a step forward from the gatekeeper model that was originally utilized by HMOs as a means of coordinating patient care. The PCMH program places a greater emphasis on quality patient care through team-based medical management as compared to the “gatekeeper” model. The problem with primary care physicians acting as gatekeepers is that it actually places more financial risk on physicians through the process of referrals resulting in a situation where it is more cost-effective to provide less care to the patient (i.e. saying specialists do not need to be brought in).
As you can imagine, such a state of affairs would result in a gradually declining level of patient care which shows why the PCMPH program is a step in the right direction towards provisioning proper care to patients. In terms of progress, Kaiser can be stated as moving towards greater levels of digitization and automation in its PCMH program. This can be seen through its online website wherein patients can choose their doctors online, custom design their treatment plans and view the progress of their tests and results without having to physically go to the doctor to get the results. This as described by Cheadle et al. (2010), helps to create a more efficient and practical system for patient care since it enables patients to choose the treatment processes they undergo while at the same time saves them significant amounts of time in regards to having to be referred to various specialists for their condition when it can all be done online.
What kind of payment method is more suitable for reimbursing PCMH?
The problem with HMOs in general as a possible method of reimbursing PCMH is that patients can only get to see specialists for particular conditions (i.e. a cardiologist, a rheumatologist, etc.) only if they can get a referral from their primary care physician. This falls under the gatekeeper model and, as a result, severely constrains the choices and capacity of patients to choose the type of healthcare they receive. Because the PCMH program is supposed to allow patients the capacity to choose their doctor without having to go through a “gatekeeper” so to speak, a standard HMO would probably be the worst possible means of reimbursing PCMH since it would in effect render the very principles of PCMH null and void. One possible solution to this would be to create a similar system as seen in the case of Kaiser Permanente wherein through its network of 36 medical centers and 14,000 medical professionals it does allow patients to choose their physicians and specialists to a certain degree. This “choice” though is limited to select list of physicians for specializations, however, it still is better than the current gatekeeper model utilized by most HMOs wherein a referral through a primary care provider is still needed whereas through Kaiser an appointment can be set up via a person’s online account without having to go through a referral via a primary care physician.
It should be noted though that one of reasons why Kaiser is capable of providing such a service is because as an integrated managed care consortium, it is capable of provisioning more specialized services in a far more efficient and cost-effective way since the doctors under its network of hospitals and care centers are paid a set salary per month regardless of the number of patients they see as compared to other doctors who are paid on the number of patients they see. As a result, “extra procedures” (i.e. methods of inflating a patient’s bill without sufficient due cause) are rare in Kaiser resulting in the healthcare provider being better equipped to handle specialized cases of healthcare as compared to other HMO providers. It is based on this that an HMO method of payment would work if it is done through integrated managed care consortiums that have networked services that allow patients to choose their method of care. If such a system cannot be implemented, then it would be unwise to implement an HMO based payment system.
PPOs can be considered a more ideal method of paying for PCMH since it allows patients to see doctors that are outside of the range of its current network. For example, if a patient had a rare skin condition and needed to be sent to a dermatologist that was outside of the current network, then a PPO would enable a patient to choose that particular doctor. The important correlation between a PPO and PCMH is the concept of choice wherein patients are given a choice as to the type of doctor and treatment they can undergo which is at the core of PCMH.
Cheadle, A., Schwartz, P. M., Rauzon, S., Beery, W. L., Gee, S., & Solomon, L. (2010). The Kaiser Permanente Community Health Initiative: Overview and Evaluation Design. American Journal Of Public Health, 100(11), 2111-2113.
Paige, S. B., Bourcier, E., Cahill, C., Hsu, C., & Kabel, C. (2012). Evaluating the Kaiser Permanente Community Fund’s Social Determinants of Health Portfolio. Foundation Review, 4(1), 68-80.
Strandberg-Larsen, M., Frølich, A., Krasnik, A., Bellows, J., Kristensen, J. K., &… Hsu, J. (2012). Self-Management Support to People with Type 2 Diabetes – A comparative study of Kaiser Permanente and the Danish Healthcare System. BMC Health Services Research, 12(1), 160-167.
Strandberg-Larsen, M., Schiøtz, M. L., Silver, J. D., Frølich, A., Andersen, J. S., Graetz, I., &… Hsu, J. (2010). Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system. BMC Health Services Research, 1091-103.