, Heritage writer
It’s official. Kaiser Permanente has acquired Group Health Cooperative, making Kaiser Permanente Washington our newest region, the first in over 30 years.
Although this merger is brand new, the two organizations began collaborating more than 65 years ago. Group Health Cooperative of Puget Sound (they dropped the “of Puget Sound” in 1995), like Kaiser Permanente, was always a mission-driven organization that approached health care in a very different way from traditional fee-for-service medicine.
In fact, few know that our common roots go as far back as 1950, just three years after Group Health Cooperative’s founding.
The relationship began in 1949 when the International Longshore and Warehouse Union [ILWU] approached Kaiser Permanente (then called the Permanente Health Plan) about taking on their membership. Initially it was the 20,000 members in the San Francisco Bay Area, with the understanding that it would soon be all of their members on the rest of the coast, from Seattle down to San Diego. Permanente and the ILWU had been in discussion since 1945. Among the many advantages raised was “The hospital’s facilities are open to all groups with no segregation of patients because of creed or color.” Imagine that.
In a 1974 interview, Kaiser Permanente founding physician Sidney Garfield, MD, reflected on this earliest relation between Kaiser Permanente and Group Health Cooperative:
We were rather anxious to get the membership of course, but we couldn’t spread our service that far. We did have a service up in Portland, so that was fine. We got the doctors up there to accept those members, they wanted to do it too. In Los Angeles we had no service. We had it in Fontana, which is quite a distance away, maybe 70 miles from San Pedro. In San Diego we had no service.
[In the Northwest] what we did was arrange with… a prepaid plan up in Seattle, Group Health Association [Cooperative] I think they call it, so we talked them into taking on Longshoremen up there and there was a prepaid plan down in San Diego, a small one, and we talked them into taking on the Longshoremen, and we tackled the Los Angeles, San Francisco, Bay Area and the San Pedro area…
The Pacific Maritime Association began making a 3 cents per man hour contribution to the Welfare Fund on December 26, 1949.
Hospital plans go into effect as of February 1, 1950. Permanente Foundation’s Health plan will cover the San Francisco, Los Angeles and Portland – Vancouver areas. There is already a setup in Portland similar to the one in the San Francisco Bay Area. Permanente will open a clinic in Wilmington, Calif., immediately upon the ratification of the Welfare Plan by all locals.
In Seattle, Wash., the Group Health Cooperative of Puget Sound made the offer of medical care on the same basis and at the same price as Permanente.
By year’s end, 90 percent of eligible ILWU member had signed up for the plan. It was voluntary; the Permanente Foundation Health Plan was committed to offering “dual choice” to groups, so that no member would feel resentful at having something forced on them.
Group Health Cooperative communicator Pat Bailey adds this point:
This contract for 2,200 ILWU enrollees for Group Health came at a time when the Cooperative was cash-starved. But as already noted, with the new enrollees came pent-up health needs. Before long, the waiting list for hernia operations numbered as many as 50.
It’s hard to overstate the deep impact that this contractually-negotiated benefit made in the lives of the ILWU members.
When the plan began, there was a big rush for treatment of such illnesses as hernias and hemorrhoids, conditions the men had suffered with and lived with for many years. They hadn’t been able to pay for medical care on their own. A 1951 brochure produced by the ILWU about the Multiphasic testing examination noted that “…many of our members have not been to the doctor until they practically collapsed on the job.”
A March 10, 1950, article in The Dispatcher put it this way:
“The Welfare Plan is the greatest thing since the hiring hall.” That’s the opinion of D.N. (Lefty) Vaughn, Local 13 longshoreman, hospitalized here under Permanente. Vaughn told Local 13 visitors last week that if it wasn’t for the Welfare Plan he would have had to sell his home in order to pay for the major operation he’s getting for nothing through the Plan.
An editorial three weeks later further explained:
Life can be beautiful if you’re healthy is the way the ad men put it. There’s no doubt they’ve got a point, though it’s oversimplified. Health is no fringe issue, not when you are required to make a choice between an operation which will allow you to go on working and living, and the home you must sell to pay for that operation. Longshoremen no longer have to make such choices. More than one home has been saved since the medical coverage section of the Welfare Plan became effective two months ago.
Kaiser Permanente and Group Health Cooperative– partnering to help working American families get good health care since 1950.
Short link to this article: http://k-p.li/2mUqseU
Thanks to Robin Walker, ILWU archivist, for help with this article.
, Heritage writer
The Automated Multiphasic Examination
Second part, follows “Screening for Better Health: Medical Care as a Right”
Last summer a major medical news story splashed across the world: “Historic Kaiser Permanente Data to Aid in Long-Term Study to Determine Extent of Ethnic Disparities in Brain Health and Dementia; new $13 million study funded by National Institute on Aging will revisit patients who were first screened as long as 50 years ago.”
Where did this remarkable trove of data come from?
In 1961 the U.S. Public Health Service awarded the Kaiser Foundation Research Institute a grant to study the automation of the multiphasic health testing it had been conducting manually for 10 years. Members would now go through the screening stations with computer cards that got marked along the way. At the end of the session, which took a couple of hours, there would now be a computerized medical record of their current health status. The Automated Multiphasic Health Test was born.
The first AMHT center was at a new building on the Oakland Hospital campus at 3779 Piedmont Ave. By the end of 1966, Kaiser Permanente had enlarged and updated its testing facility and laboratories nearby at a state-of-the-art center at 3772 Howe Street, and expanded the computer center and offices in the Piedmont building. A second center in San Francisco was linked to the mainframe computer in Oakland.
Dr. Collen, in the Journal of the American Medical Association (1966), accurately predicted that “The advent of automation and computers may introduce a new era of preventive medicine … [The computer] will probably have the greatest technological impact on medical science since the invention of the microscope.”
The AMHT continued to be seen as a vital tool in the diagnosis and treatment of occupational and industrial illnesses. A 1967 article in the Archives of Environmental Health discussed the employment data gathered, which included a list of 170 occupational titles and a battery of work-related health questions. “The computer storage of data on more than 40,000 adults annually permits extensive epidemiological research, especially directed toward the preventive aspects of chronic disease.”
It wasn’t just union members who benefitted. The Modern Hospital, May 1966 called the periodic health examinations to more than 4,000 patients monthly “… an impressive investment in the concept of ‘health medicine.’”
The test expanded to about 20 stations, measuring everything from hearing to heart function. It even went beyond mere testing – if recommended, a patient could get a tetanus booster via the new high-pressure injector system.
A 1970 article by Dr. Garfield in the prestigious New England Journal of Medicine with the provocative title “Multiphasic Health Testing and Medical Care as a Right” began with this abstract:
Although no long-term evidence exists that the course of disease is influenced by multiphasic health testing, this is largely irrelevant. Such programs are essential for other very important reasons. The existing and spreading concept of medical care as a right, with its elimination of personally paid fees, is creating a demand for periodic health checkups and health appraisals. This demand cannot be met by traditional methods totally involving the physician without great waste of doctor time.
Multiphasic health testing can help separate the entry mix of patients into the well, the asymptomatic sick and the sick. This separation makes possible optimum use of physicians’ services, which can be devoted to the area where they are most needed: the care of the sick.
The efficiencies of the AMHT were sufficient that these programs were sometimes adopted by private practice, large companies, and public health agencies. Dr. Collen remarked:
It is still of great interest to me and much personal satisfaction that the AMHT is still flourishing in Japan, Taiwan, and in China; and in the past when I visited them I found the AMHT centers in Japan to be primarily employer-sponsored for employees. I found the newest AMHT centers in Taiwan and China to be for-profit, marvels of efficiency and associated with health education centers open to the public, and with a high level of provider and patient satisfaction.
But despite the AMHT’s popularity, it was discontinued by Kaiser Permanente by the late 1970s when a federal grant supporting the work dried up and Kaiser Permanente declined to commit further resources.
Dr. Collen himself noted some of the challenges to quantifying the benefits of screening:
…Epidemiologists required us to report on gross mortality, and since the potentially postponable conditions comprised only about 15 percent of all the causes of death, most people died from other conditions … some of the criticism of urging checkups is based upon the fact that one does not decrease total gross mortality. That is, everyone eventually dies from something.
Gary Friedman, MD, former director of Kaiser Permanente’s Division of Research, recently explained additional medical limitations to the AMHT:
Initial enthusiasm for multiphasic health screening was tempered by experience in using it and by scientific studies that did not confirm benefits vs. costs of specific screening tests. For example, it was initially hoped that routine chest x-rays, included in AMHT, would lead to early detection and increased curability of lung cancer. Studies did not confirm this benefit. A yes/no question about chest pain provoked by exercise and relieved by rest was included in the AMHT symptom questionnaire. Although a yes answer seemed almost diagnostic of angina pectoris, this often did not prove to be the case in the follow-up examination by the physician, who could question the patient in greater detail, consuming valuable time.
Clearly however, the value of some screening tests has been amply confirmed. Finding and treating high blood pressure in asymptomatic individuals prevents strokes. And screening for colorectal cancer by the various tests available can lead to early detection and cure, or the removal of polyps that could later progress to cancer.
Despite these issues, Dr. Collen defended the value of the AMHT in a 1986 UC Berkeley oral history by Sally Smith Hughes:
…The study [on AMHT] did clearly demonstrate that for those conditions that are potentially postponable, there is a significant decrease in mortality.
He went on to note larger policy and commercial impediments to the AMHT:
Blue Cross/Blue Shield and other indemnity insurers to this day still do not pay for checkups. They take the position that periodic health checkups are schedulable and elective, so are not insurable events. Medicare to this day does not pay for checkups. The contrast, in other countries, like in Japan and in France, their social security and governmental supportive systems pay for periodic health checkups for well people, but do not pay for sick care. Just the opposite from the U.S. So if our Public Health Service is so interested in
preventive medicine, why do they fail to support the financing of checkups? A very key reason that multiphasic testing has not proliferated in the United States is because it is not reimbursed by any of the insuring agents. That has been reported by vendors who try to sell the systems.
I should point out that the Public Health Service had asked us to patent the system because it was an invention. Whether I was right or wrong, I refused to do so. I felt that it should be in the public domain, and it is. It’s never been patented.
Dr. Collen concluded with deep pride in the accomplishments:
We actually developed the most comprehensive inpatient and outpatient medical information system in the world. And this book, Hospital Computer Systems, describes that. There were only a half-a dozen others in the world that were doing that.
As the 2016 medical news story about the persistent value of the AMHT data shows, this was a significant accomplishment in medical practice. Thank you, Dr. Collen.
Short link to this article: http://k-p.li/2n00mcW
, Heritage writer
[Part one of two]
For many years a hallmark of Kaiser Permanente’s preventive health care program was a battery of tests, designed to alert doctors to trends and red flags in a patient’s health. And it started with service to industrial workers.
Lester Breslow, MD, published a seminal article in the March 1950 American Journal of Public Health titled “Multiphasic Screening Examinations: An Extension of the Mass Screening Technique.” Dr. Breslow, who worked for the California State Department of Public Health in Berkeley, challenged the limitations of periodic health examinations, and proposed the value of an integrated battery of preliminary examinations – a “multiphasic examination.” The advantages included a single combined medical record, cost savings, and improved diagnoses. One passage in Dr. Breslow’s article stood out:
“This survey can be conducted in a time not much greater than would be required for screening for a single disease. Where such screening procedures are carried out among industrial populations the time element is especially important.”
At that time, the Permanente Health Plan was expanding to the public after having only served Henry J. Kaiser’s World War II employees, and much of that growth was from unions. Dr. Breslow had been a college classmate of Kaiser Permanente’s Dr. Morris Collen, and the AJPH article offered a solution to the challenges of bringing in large numbers of industrial members with physically demanding jobs and poor health care.
Since the main medical competitors, Blue Cross/Blue Shield, did not provide health checkups unless one had a medical complaint, the Permanente facilities saw a surge in well-patient testing that began to drain the system. Searching for solutions, Dr. Collen spoke with Dr. Breslow, who suggested setting up a multiphasic screening for a large new member organization – the International Longshore and Warehouse Union. Although the screening was coordinated under Permanente’s leadership, it included the cooperation of the United States Public Health Service, the California State Department of Health, the San Francisco Public Health Department, the Bureau of Vocational Rehabilitation, and the San Francisco Tuberculosis Association.
The screening was seen as a groundbreaking step public health. The ILWU Dispatcher article May 11, 1951 proclaimed:
The longshoremen’s program represents pioneer work in preventive medicine—the science of keeping people healthy. Multiple health tests for such a large group are a new procedure, in use only since 1948 and scientifically proved to be effective in detecting disease while there is still time for treatment.
Dr. Collen proceeded try his first group test at the ILWU’s Local 10 hall at pier 18 in San Francisco, and screened several thousand longshoremen. An article in The Dispatcher from August 17, 1951, was titled “ILWU Waterfront Health Tests ‘Complete Success’; 4,002 Go Through” boasted:
Follow-up tests and treatment are now being given to members whose test results showed any signs of disease by a special team of Permanente doctors assigned to the ILWU under the ILWU·PMA [Pacific Maritime Association] Welfare Plan.
At a dinner for all the people who worked on the project, Permanente Health Plan, Director Dr. E. Richard Weinerman said the health test program was a “complete success . . . The fact that this program was the first to be organized by a union, the first to provide so comprehensive an array of tests and the first to assure complete medical follow-up through the health plan made it an outstanding contribution to the field of preventive medicine.”
Dr. Weinerman also noted the role of what we now call “culturally competent care.” In a Dispatcher article July 6, 1951, he said “In order to condition [our physicians] to do the best possible analysis, the union is taking them on a tour of the waterfront to observe working conditions. Then they will be able, to understand clearly how longshoremen work, and they can interpret symptoms more accurately.”
Dr. Collen later recalled the next steps of expanding the screening to all Permanente members in his oral history:
We started our multiphasic program in the Oakland clinic [on November 29, 1951]… After the clinics closed at five-thirty, we used the existing office space in the surgery clinic. We developed a whole series of arrows and put colored tapes on the floors so that patients would go in through the various rooms and have their height, weight, blood pressure, and other physiological measures taken, and then fill out a history form. Then they would be directed to the laboratory for blood and urine tests, to the x-ray department for a chest x-ray, and to the electrocardiography department for an electrocardiogram. In that way, we didn’t require any extra equipment or any extra facility space. We developed a team of personnel that would work in the evenings from about five-thirty to eight, and we examined some twenty-five to thirty patients every evening that way at a very low cost.
In 1952, the Kaiser Permanente clinic at 515 Market Street in San Francisco also opened a Multiphasic Health Test facility in a space that had formerly been used as an orthopedic clinic.
The process consisted of about 15 procedures and only required the presence of a single physician, assisted by paramedics. Dr. Collen went on to explain the beautiful medical logic of the testing:
. . . Health is the only condition in life when you find people are medically similar. That is, healthy people have a relatively normal distribution of their tests and measurements so that you can develop routine repetitive procedures to do these tests. The health checkup, the evaluation of a normal well person, is the most routine, repetitive procedure in medicine.
As soon as one has a variation from normal, which is the basic definition of being ill or sick, then one becomes unique. Every diabetic is different; every hypertensive is different, and a diabetic with hypertension is even more complicated. So it is difficult to develop routine rules for sick people. But for normal people, and by definition 95 percent of healthy people are within normal limits, you can develop routine repetitive procedures. And that is the secret of the efficiency and economy of a programmed, systematized, multiphasic checkup.
An article in the Permanente newsletter Planning for Health touted the Multiphasic:
A broad stride in the practice of Permanente’s fundamental principle of preventive medicine was accomplished with the recent inauguration of the Multiphasic Health Check-up program at the Oakland and San Francisco medical centers. A new type of general medical examination, Multiphasic Check-up, is based on the premise that early diagnosis and adequate treatment can materially reduce the ill effects from significant diseases.
By the mid-1950s, 30 to 40 percent of all new members were choosing the multiphasic on their first visit.
However, in the early 1960s changes in technology would transform the examination. And the future was . . . computers.
Short link to this article: http://k-p.li/2mtLDb6
Special thanks to ILWU archivist Robin Walker for her help with this article.
By Ginny McPartland
Affordable health care was an elusive commodity in 1930s America. Medical practice was becoming more sophisticated, and qualified doctors were in great demand. Consequently, private professional care was out of reach for many Americans. Employer-sponsored health plans started to spring up in the late 1930s and early 1940s, but even those progressive prepaid plans were slow to add workers’ families to the coverage.
Permanente medicine, developed by industrialist Henry J. Kaiser and enterprising physician Sidney Garfield, was launched to take care of workers in Kaiser’s West Coast shipyards. The two had done this before: Garfield had set up a prepaid plan for workers on the Los Angeles Aqueduct project in 1933, and he and Kaiser had teamed up to care for workers at the Grand Coulee Dam in Washington state in the late 1930s.
The Kaiser-Garfield prepaid, group practice plan for shipard workers was progressive and exemplary by all accounts. Unlimited medical care for the individual workers was provided for 50 cents per week. But Garfield and his doctors had their hands full, so initially only the worker – not the family members – was covered by the health plan.
Stuart Lester of “Medical Economics,” writes in the February 1944 issue: “The principal threat to the permanence of the Permanente Foundation – which provides virtually unlimited medical care for 130,000 Kaiser shipyard workers in two states* is the workers’ complaint that it makes no provision for their families.”
The article continues: “The family problem is especially acute in the shipyard town of Richmond, Calif., where the ratio of physicians to population is something like 1 to 4,000 and where the only hospital facilities of any consequence are those provided by Kaiser’s Richmond Field Hospital.”
In Richmond, Portland (Oregon) and Vancouver (Wash.), nonsubscriber family members were treated for a fee. Office visits were $2.25. For maternity, $200 covered prenatal care, delivery, hospitalization, C-section if required, postnatal care, and care for the newborn. Employees at the Kaiser Fontana steel plant in Southern California were the exception. In 1944, Fontana workers could purchase complete coverage for a family of four for $1.80 a week.
Physicians debate how to cover families
“Medical Economics” writer Lester refers to three possible solutions proposed at the time: an expansion of the Permanente plan to include family members; an expansion into the Richmond area by the California Physicians’ Services (CPS) prepaid plan as operating in other war industry communities; or the development of a prepaid arrangement for families through a private physician network.
The California Medical Association (CMA) launched the CPS in 1939 to offer prepaid care to low-income families in California. Initially, the physicians association’s plan offered a “full coverage contract” that included all outpatient physician services. In 1942, CPS excluded the first two doctor visits from coverage to make the plan financially viable, according to the April 1943 issue of the CMA’s “California and Western Medicine.” In 1943, CPS, the precursor to Blue Shield, had 39,000 commercial members, 5,100 government rural health program subscribers and a total of 32,000 war housing resident members in Vallejo, Marin, Los Angeles and San Diego.
“Dr. Sidney R. Garfield, Kaiser’s medical director, sees two obstacles to an extension of his program to include families: One is opposition by the local medical societies. The other is lack of facilities – particularly in the hospital at Richmond,” Lester wrote in “Medical Economics.” The article noted that expansions of the Richmond Field Hospital and the Permanente Foundation Hospital in Oakland were under way.
The second proposal – having CPS provide family coverage for Richmond area workers – had been tried previously and failed. In 1942, CPS had offered a family plan in nearby El Cerrito and was not able to attract enough members. The coverage for non-Kaiser workers was enticing: a $5 flat fee no matter how many family members. It wasn’t practical for Kaiser employees, however. To take advantage of the CPS plan, a worker would have to buy his or her own coverage for $2.16 a month and then pay $5 for the rest of the family.
According to the “Medical Economics” article, solving of the family care issue by fee-for-service doctors was doomed from the beginning. A shortage of private doctors and inadequacy of medical facilities made any such plan unfeasible. Also, California private practice physicians were admittedly just tolerating the Permanente model of prepaid, group practice with salaried physicians. One private doctor told the magazine: “The Kaiser-Garfield groups are doing a job right now that is aiding the war effort, and are doing it well. But we don’t like their system.”
Kaiser extends coverage to shipyard families
In the spring of 1945, the Permanente medical plan, now with expanded facilities to accommodate more members, was extended to the families of all Kaiser shipyard workers. “Medical Economics” reported the details of the Permanente family care plan: for $117 a year ($2.25 per week) for a family of four, coverage was extensive. It included 111 days of hospitalization, complete diagnostic services, necessary drugs, physician services at home or medical office, major and minor surgery, and ambulance service within a 30-mile radius. Members paid an extra charge of $60 for comprehensive maternity care, $15 for a tonsillectomy and $2 for a house call.
“Medical Economics” concluded the article with this statement: “Insurance men pointed out that the total annual cost for a family of four, $117 a year, is an amount which has generally proved to be too high for any wide participation on a voluntary basis.”
Workers who left the shipyards could maintain coverage for a “slightly higher” premium as long as they continued to live in the service area. This retention provision foreshadowed Kaiser and Garfield’s plans to keep the Permanente medical care plan alive after the war industries shut down.
*Kaiser shipyards health plan actually took care of workers in three states, California, Washington and Oregon, and enrolled up to 190,000 members at the peak of the war.