By Ginny McPartland
It’s been a quarter of a century since Kaiser Permanente (KP) established a prepaid medical care outpost in Fresno, then unbroken territory for the health plan. Since its opening in 1986, KP Fresno has grown from 400 initial area members to over 100,000 today. Its facilities have expanded from a remodeled space in a shopping center to several large clinics and a hospital the Fresno Bee newspaper labeled KP’s local “crown jewel” when it opened in 1995.
“It’s big, bright and modern and epitomizes health care competition in Fresno,” the Bee writer effused.
KP officials began to ponder a move into Fresno in 1985 when large statewide employers began to expand into the burgeoning Central Valley. The health plan already had a clinic in Stockton, which is north of Fresno and south of Sacramento.
It made sense to go to Fresno since KP health plan members were moving there and getting their care at other KP facilities, the closest of which was three hours away. Also, employees of big companies, such as Bank of America, Pacific Gas & Electric Company and Pac Bell were retiring and settling in Fresno and other communities in the Central Valley.
“These employers wanted the advantages of having similar benefits for their employees in multiple sites, and the employees wanted access to the same quality of care and service they had grown to appreciate in the Bay Area and Southern California,” explained Larry Coble, MD, retired Fresno pediatrician and physician-in-chief. Dr. Coble wrote a history of the first 13 years of KP Fresno when he retired in 1999.
Behind the scenes, high level KP leaders had been debating about where the boundary should be between Northern California region, with a facility in Stockton, and Southern California region, which was developing a presence in Bakersfield. The argument was settled when Northern California entered Fresno and thus staked its claim in the Central Valley.
To launch a KP facility in Fresno, whose isolation made it different from most other expansion areas, KP leaders had to start at square one. No existing facility could take Fresno under its wing as a satellite.
Checking out Fresno’s potential
In 1984, TPMG executive director Bruce Sams, MD, tapped Albert Kahane, MD, associate executive director and former Sacramento Medical Center’s physician-in- chief, to work with the regional medical group to assess the potential for KP’s entry into Fresno. By early 1985, the decision to go to Fresno was made.
As the medical group facilities planning liaison, Dr. Kahane was called on to spearhead the acquisition and conversion of clinic space where the Fresno medical care program would be launched. He was also responsible for contracting for community hospital beds for KP’s patients.
In the fall of 1985, The Permanente Medical Group (TPMG) and health plan leaders began to assemble a team to make Fresno a reality. They set the opening date for July 1, 1986, and leased a four-story building at First and Shaw streets in the former Fashion Fair Plaza. Remodeling of space for the primary care areas began right away.
The start-up team, affectionately called the A-team, was selected from the Sacramento service area. Led by Dr. Coble, the team members were: John Bowden, medical facility administrator; Shirley Edmons, RN, nursing director; Toni Hays, Support Services manager; and Edie Yoder as secretary.
Selling Kaiser Permanente
In the spring of 1986, Dr. Coble began his quest for willing professionals to make up the KP core team of primary care staff physicians, contracted specialists and laboratory and x-ray professionals. “(I was) literally going from door to door meeting with physicians, optometrists, podiatrists, laboratory supervisors, etc. At times I felt like a salesman, handing out my card wherever I went. . .that’s exactly what I was doing, selling Kaiser Permanente.”
The first patient was 19-month-old Sara Beadle, who was brought in by her mother (Debra Shriver-Sprinkel) at 8:40 a.m. on the first day. She grew up to be a healthy young woman and distinguished herself on Fresno State University’s equestrian team in the 2003-2004 season. She studied philosophy and business in the Fresno pre-law program.
Most local residents and employers welcome KP
Dr. Coble says the people of Fresno, especially the major employers, for the most part welcomed Kaiser Permanente to the Fresno community. It took the Fresno City Council five minutes to approve a zoning change for 38 acres at Fresno Street and Alluvial Avenue to allow KP to build a 200-bed hospital and medical offices for 180 physicians. At the time, the health plan had no immediate plans to build a hospital, but opened a huge outpatient facility at the site in 1991 and added an outpatient surgery center in 1992.
There was, however, initial resistance from the Fresno area fee-for-service physicians who objected to KP’s prepaid group practice. Dr. Coble recalls: “One very ugly situation occurred in which someone obtained a copy of our contracted physician list and posted it on (a local) hospital’s physician lounge bulletin board.” The list of specialists taking referrals from KP doctors was circled with black crepe, the symbolic “black ball” meant to intimidate physicians from supporting KP.
Dr. Kahane says he also encountered resistance when he negotiated with local hospital administrators for KP’s use of hospital beds. He says favorable contracts were elusive because hospital leaders believed KP would eventually build its own hospital in Fresno. He told local hospital officials: “Whether it costs us less (to operate our own hospital) or not is your decision.” He explained that if the community hospitals charged prohibitive fees for contracted beds, KP would be forced to build its own Fresno hospital. “And that is exactly what happened,” he said in a recent interview.
Fresno KP gets its own medical center
In the early 1990s, with rapidly growing membership and medical staff, KP Fresno leaders started making plans for a hospital of their own. Construction began in 1993 on the site at Fresno Street north of Herndon Avenue. In 1994, Ed Glavis was appointed as administrator of the new hospital; Maura Hopkins, RN, as nursing director; and Davidson Neukom as facilities manager.
When the new hospital opened in February 1995, the Fresno Bee said: “The Kaiser Permanente Hospital is the crown jewel in a $100 million Kaiser building project in Fresno, including the $30 million ancillary building which opened in late 1992.”
“I’m terribly excited,” Dr. Coble told the Fresno Bee. “It’s going to be easier because our physicians now will be able to literally walk down the hall to see their (hospitalized) patients. . . In addition, he said, all the ancillary services, such as laboratory, x-ray and pharmacies are close at hand . . . It’s professionally a very satisfying way to provide health care.”
Opening just in time for laboring mom
On opening day, KP Fresno swung open the doors to the Birthing Center and the Emergency Department. When the maternity staff unlocked the door at 6 a.m., they were met by expectant mom Angela Ballew who was in labor and gave birth to a daughter, Madison Ballew, the same day.
The rest of the hospital complex was opened in October of 1995. Having received “full accreditation with commendation,” Dr. Coble reported in his memoir: “We were a full-scale, high-quality medical group and hospital!”
Continued growth and success
From its early milestones, KP Fresno has continued to grow and prosper. The Fresno KP community has been honored recently for its commitment to reduce waste and prevent pollution in its facilities. The staff has also been recognized for its excellence in employee wellness efforts and for its work to overcome obesity in the community.
KP’s Fresno Medical Center, which stopped accepting free baby formula years ago, is close to being designated as Baby-Friendly* with 75.8% of new mothers exclusively breastfeeding their newborns, the highest rate in Fresno County in 2009. The center’s maternity staff places an emphasis on breastfeeding and discourages formula supplementation for infants whose mothers intend to breastfeed exclusively.
KP’s presence in the rest of the Central Valley has continued to expand as well. In 2008, the health plan opened another exquisitely designed hospital to serve the area. The new Modesto Medical Center** follows the current version of the evolving KP hospital design template, which incorporates functionality, as well as sustainability, patient comfort, optimal use of natural light, staff efficiency and accommodation of the latest medical technology.
*Baby-Friendly USA is a national campaign to encourage breastfeeding. Fourteen of Kaiser Permanente’s facilities have received the designation, and KP leaders have vowed to have all 29 medical centers called out as “baby friendly” by Jan. 1, 2013. Already designated are: Los Angeles, San Diego, Fontana, Downey, Riverside, Anaheim, Panorama City, Irvine, Baldwin Park, and Woodland Hills in Southern California; Hayward and South Sacramento in Northern California; Honolulu, HI, and Clackamas, OR.
**For more about the KP facility template, click here.
By Ginny McPartland
Thanks to Sue Odneal, a Kaiser Permanente information security employee, I recently was turned on to a series of holiday posters from the 1980s that are amazing gems from KP’s past. Sue, who has worked for KP for 36 years in Vallejo, Oakland and Walnut Creek, found three of the posters among her things and wanted to donate them to the Heritage archives.
I was thrilled to hear from Sue, and I emailed her right back and said: “Please send them!” Once I saw three of the full-size posters,
published from 1982 to 1988 in the KP Reporter, I wanted to find the rest of the six-poster series.
Looking through our archived KP Reporters, Heritage writer Laura Thomas and I found the rest of the six and were completely charmed. Next, knowing that Molly (Prescott) Porter, director of KP International today, was the employee publication’s editor in the 1980s, I contacted her to jog her memory.
“It’s so funny to be reminded of these things,” Molly wrote. “Yes, I remember; and I hired Jonathon Nix, a talented illustrator. I guess we (Molly and Gretchen Gundrum) made a decision to publish and insert these into the internal magazine as a holiday present to (30,000) Northern California employees and physicians – perhaps to put up in their cubes or take home.”
Sue Odneal was one of those employees: “We really enjoyed having these as part of our office holiday decorations,” she recalled.
Poster artist reminisces about holiday project
Artist Jonathon Nix was not hard to find. I got his email address from his Web site and jogged his memory too. “Yes Virginia, there really is an illustrator,” he wrote back. “Um, sorry about that. Couldn’t resist.” (Apropos since my email name is Virginia.) He continued: “Yes, I am the illustrator of those posters . . . I’m tickled to hear that you’re thinking of writing about
them. . . To be honest, I don’t remember every one of them, so it will be fun to see them when you send them.”
My colleague Lincoln Cushing scanned the posters and we sent the PDFs to Jonathon. A few days later I had the chance to talk to the artist, who now lives on the East Coast. “I was fairly surprised to see there were six of these,” Jonathon told me. “Before you
got in touch I would have said that I did, maybe three. It was really fun to see these images again and be reminded of the project. . . .Molly used a very light hand in directing these,” Jonathon recalled. The artwork was meant to feature children and each poster to promote one very simple idea.
As it happened, the years during which Jonathon designed the KP holiday posters made up a crucial period of his life. Living in San Francisco with every intention of moving back to his hometown of Tucson, Jonathon was sidetracked when he met and married his wife, Andrea, in the late 1970s. The couple had their first child, Olivia, while living in the Bay Area.
Illustrator finds inspiration in real life
Looking at the rediscovered posters, Jonathon felt the memories of his young family flowing back. “What comes back the strongest is that the little Japanese doll character, which appears in all of them, was modeled on my daughter Olivia who is now 31 and is a mom,” Jonathon told me. “She was definitely that character although we never put up her hair like that, thank goodness. I always considered her a pivotal character in all of the posters.”
Jonathon made illustrations for the Kaiser Permanente publication for several years before deciding in 1983 to move to western Massachusetts. The poster created immediately after the move reflects the inspiration Jonathon felt from Norman Rockwell who had lived and worked in the Berkshires where the Nix family settled. “We actually knew someone who had been a model for Rockwell when she was a kid,” he said.
That poster shows a hospital scene where a red-headed girl with long braids, in a wheelchair and her leg in a cast, leads a parade of toys down the corridor. A startled nurse resembling a Rockwell character looks on in horror. “(From the nurse’s point of view, things like that) “are not supposed to happen in a hospital and she’s expressing that,” Jonathon said with a laugh.
The red-haired girl, inspired by Jonathon’s niece Sarah, creates a jovial holiday atmosphere in an often cheerless place – a hospital ward. “We were thinking about children’s wards and creating something that would reach out to families who had children hospitalized at that time of year, which is always a very poignant thing,” he said.
In 1984, Jonathon got his inspiration for the holiday poster from the birth of his son, Edward. The artwork shows Andrea, his wife, his newborn son nestled in her arms and Olivia sitting at her mother’s side on the hospital bed. Peering over the bedrail are Olivia’s teddy bear, another recurring character in the series, and an amiable Pinocchio.
At the foot of the bed is Pierrette, the female Pierrot character that originated in Commedia dell’arte or Italian Comedy. Dressed in flowing diamond-patterned trousers and a layered harlequin collar, Pierrette also appears in many of the posters. Young Olivia had a Pierrette doll among her toys, and Jonathon found the chic yet sweet and cute character added a little sophistication to his creations.
Healthy lifestyle themes illustrated
In posters presented to KP employees during the holidays from 1985 to 1988, healthy lifestyle messages were integrated into Jonathon’s whimsical scenes. In 1985, it was all about exercise; in 1986 and 1987, the message was automobile safety; and in 1988, it was about healthy eating.
Jonathon says the 1986 poster with the car on the checkerboard road was influenced somewhat by a 1951 Plymouth that he drove in Massachusetts at the time. The obvious yellow seatbelts everyone was wearing and the “healthy and safe” message illustrate Henry Kaiser’s early interest in the 1950s in highway safety.
“It was such a happy collaboration with Molly (Prescott Porter). I really enjoyed working with her, and I think her boss (Gretchen Gundrum, director of communications) was also influential in providing direction on these.”
Jonathon said the posters were meant to represent KP’s diversity and to avoid references to any particular faith. However, reflecting on the imagery of the 1980s posters, he sees how some of the symbols, such as Santa Claus driving a car and the wreaths and pieces of holly sprinkled throughout, would not be considered strictly secular in today’s world.
Although Jonathon didn’t remember all the posters, he didn’t forget his first. “The watercolor artwork for the earliest one, with the Peace on Earth theme, was framed and hung in Olivia’s room the whole time she was growing up. That room is a guest room now, and the illustration’s still in there,” Jonathon reported.
So what has Jonathon been up to for the past 30 years? He has had his own graphic design business in Massachusetts and continues to paint and sculpt on the side. He’s won many awards and participated in many exhibitions. Currently, Jonathon designs full time for the Met Life insurance company in Boston. You can learn more about Jonathon Nix on his Web site: http://www.jonnix.net
The epidemic appears
AIDS was first reported in the summer of 1981. The next year, when the Kaiser Permanente San Francisco Medical Center began treating its first patients, diagnosis and treatment protocols were in their infancy. Doctors, nurses, administrators, and other caregivers struggled to know what to do.
Sometimes standard procedures worked fine, other times they were inadequate. One early conflict erupted in 1983 when two nurses at a Santa Clara, Calif., hospital (not a Kaiser Permanente facility) resigned over a dispute regarding caregiver safeguards in that facility’s first AIDS case. “I think most nurses would agree. . . There really isn’t anyone who wants to go in the room,” one nurse said.
At Kaiser Permanente San Francisco, Infection Control nurse Barbara Lamberto described Kaiser Permanente’s response:
“We called a department head meeting immediately [and] we talked about our personnel policies and our posture about that kind of situation, and I think in the long run it made a difference because everybody knew [that] this is how we felt. We are a health care organization. We are here to care for patients.” 2
Michael Allerton, Operations and Policy Practice Leader for The Permanente Medical Group, describes the situation as he saw it: “Here was a disease that was invariably fatal, in a horrible way, and nobody knew where it came from, how it was transmitted. . . and in this incredible environment of fear and anxiety, our doctors walked in those rooms. Our nurses walked in those rooms. Our engineers went in to fix TVs. We had people who really rose to the occasion.” 3
The lack of solid data compounded treatment of “the mysterious disease” in unexpected ways. In a 1985 interview, Kaiser Permanente San Francisco RN Grace Rico-Peña explained the challenge in the early years:
“This is very different than any other illness we’ve needed to educate about. We’re trying to dispel myths and rumors. When news media reports stories about AIDS they have a certain bias — they want to make things seem a little more dramatic, a little more exciting, and so they highlight certain parts of the story and get everybody all charged up about it.
“There are a lot of people with crazy ideas about AIDS. I remember one story about a bus driver who didn’t want to take money when he was in the “gay areas,” people who don’t want to wait on people. That’s part of our getting sensitized and taking care of these patients. AIDS patients frequently become social lepers.” 4
She describes how Kaiser Permanente responded with reason and balance:
“Our philosophy in our educational approach, which has been dictated by our top level administration here in Epidemiology, has been to not let ourselves get carried off into emotion, or political controversies, but to educate very solidly along the lines of the information that’s known. We’ve done educational programming always on the facts. [We ask] “What are our patients’ needs, how are we going to meet those needs?”
Patients get involved in care
And, as is true with all quality care, part of the solution came from the patients themselves. Tom Waddell, Olympic decathlete and a physician at San Francisco General Hospital’s emergency department, was diagnosed with AIDS in 1986.
Initially publicly critical of the treatment of AIDS patients at Kaiser Permanente San Francisco, he fought for better care. “I made a lot of noise,” he said. Other patients did so as well. On June 8, 1988, the Kaiser Patient Advocacy Union (with the suitably explosive sounding acronym “K-PAU”) was formed, demanding a voice in a range of issues. This was a life-and-death issue, and emotions flared.
But, as Dr. Waddell later admitted, “Much to Kaiser’s credit they responded. I think they may now have a model program for treating AIDS patients.” 5 It was clear that motivated, informed patients needed to be part of the solution.
An HIV Support Group Program was established in 1988 at Kaiser Permanente San Francisco, and the next year a system-wide Kaiser Permanente HIV Member Advisory Panel was formed. In 1998, Kaiser Permanente hired the top San Francisco HIV specialist, Dr. Stephen Follansbee.
Documentary highlights Kaiser Permanente’s central role
In the year 2000, Critical Condition, an independent three-hour documentary about the politics of managed care, observed this high-stakes match between institution and critics. One segment included footage of AIDS activists picketing Kaiser Permanente, angry that it moved slowly and would not prescribe medication other than standard and approved drugs. 6
Tensions were high and tempers flared, but the strategic choice of Kaiser as a target was revealing:
“We only picketed Kaiser — not because it was the worst but because you knew where Kaiser was. It’s like the big kid on the block. If you can bring that kid to his knees, the others are going to get in line also.” 7
Another protestor reflected on the choice: “Do I think those protests were effective? Absolutely. I think it slapped Kaiser in the face and I think Kaiser stood up to it and said, ‘Okay. What can we do here?’ ”
A third activist agreed: “The fact is we still have to acknowledge that Kaiser is the only HMO that I know of that’s ever allowed the members to come in and be part of the process.” 8
The strength of many
The San Francisco Bay Area quickly became one of the national centers confronting the epidemic. By 1989 two cities (San Francisco and Oakland) accounted for 67% of the region’s cases. But other Kaiser Permanente regions were affected as well and mounted their own responses.
In 1989 Kaiser Permanente Colorado created an AIDS-specific social services program to help patients manage their own care, led by Barry Glass. Glass’ holistic model proved so effective that it was extended into other areas, including care of the elderly and those with catastrophic illness. Broader health care lessons were being learned.
Some answers were found through the strength of massed medical resources. In 1987 Kaiser Permanente established a multidisciplinary Interregional AIDS Task Force, expanding to an Interregional AIDS Committee the following year.
James Vohs, Kaiser Permanente health plan and hospital president and CEO in the 1980s, reflected on that process: “One of the best interregional committees that we established was in response to the AIDS epidemic. It was an excellent way to educate our other regions on the basis of the experience that we had in Northern California, especially because we had so many AIDS cases.
“Kaiser covered something like 2 percent of the population of the United States when I was there, but we had about 5 percent of the AIDS cases. . . Having the Interregional AIDS Committee was very, very helpful in providing a good knowledge base of what was working, what wasn’t working, and how to organize services. It was extremely successful.” 9
Kaiser Permanente continues to lead
At the 30-year anniversary of the first diagnosis of the mysterious disease, Kaiser Permanente continues to be a leader in AIDS treatment and research, and in partnering with community-based efforts. Kaiser Permanente Southern California has provided grants totaling over $4 million to nonprofit organizations for a variety of services for people living with HIV and AIDS, including dental care, youth education and screening programs.
The nature of the epidemic has changed, but the work remains, and Kaiser Permanente has demonstrated its commitment to applying the full weight of its health care resources to finding solutions.
Learn more about Kaiser Permanente’s response to the AIDS epidemic at the Center for Total Health.
1 Spokane, Washington Spokesman-Review, June 12, 1983.
2 Transcript from Kaiser Permanente video interview, 3/1985; HIS07-508
3 Kaiser Permanente: 30 Years of HIV/AIDS with Coordinated Care, Compassion, and Courage, video produced by the Kaiser Permanente BSCPR Department winter 2011.
4 Transcript from Kaiser Permanente video interview, 3/1985; HIS07-509
5 Article in Spectrum, Summer 1987, p. 7.
6 Jay Lubbers, from film transcript, available at http://www.hedricksmith.com/site_criticalcondition/index.htm
7 Dave Mahon, from film transcript, ibid.
8 Mr. Sokolksi, from film transcript, ibid.
9 James Vohs interview, courtesy of Regional Oral History Office. The Bancroft Library. University of California, Berkeley. Berkeley, Calif., 94720-6000; http://bancroft.berkeley.edu/ROHO
http://content.cdlib.org/view?docId=hb8t1nb3kr&brand=calisphere“Ascending the Ranks of Management, Kaiser Permanente Medical Care Program, 1957-1992,” by Vohs, James A.; Malca Chall, editor,1999 (issued)