Everybody complains about the high cost of pharmaceuticals in the United States. Medication that is within one’s budget can make the difference between a course of treatment that is successful and one that isn’t. Kaiser Permanente is part of a coalition of health care organizations and other stakeholders determined to make drugs for health more affordable. But few know that our efforts to bring down drug costs began during World War II, when we created our own in-house drug manufacturing capability.
One of our emeritus physicians, Morris Collen, MD, spoke about it in a 1986 oral history transcript:
During the war, since the purchase of medications was very expensive, Dr. Garfield set up Royfield, which is a combination of syllables for Sidney Roy Garfield – Roy and Field. Julian Weiss was our first director of pharmacies. I remember we had an old barn and in it they made most of our medications. I recall that they stamped out the pills for common drugs like Donnatal, and that was our Rx number five. Donnatal, Phenobarbital, and aspirin–we had a formulary, which contained a majority of the common drugs we used. At considerable savings, Royfield stamped out all these pills, made all the cough medicines, and all that sort of stuff.
On October 13, 1943, Permanente Foundation Health Plan physicians Sidney Garfield (general partner) and Cecil Cutting (special partner) formed a limited partnership titled “Royfield & Company” to supply many needed drugs and medications for the hospital, clinics, and first-aid stations operated by the Foundation. To capitalize the partnership, Garfield put up $15,000 and Cutting put up $5,000. Dr. John Smillie’s book about the history of the Permanente Medical Group, Can Physicians Manage the Quality and Costs of Health Care? described the importance of this effort:
…Garfield introduced into the Foundation program a capacity for in-house drug manufacture that would make the future Kaiser-Permanente Health Plan the largest private prescription drug distributor in the United States.
Royfield operated out of a secure warehouse not far from the flagship Kaiser Permanente Oakland hospital near 51st Street and Broadway, where trucks could drive inside and securely load these crime-magnet products.
In 1952 Royfield became formally integrated into the health plan as Dapite. The program was highlighted in a TIME magazine article from 1962, “Prepaid Medical Care: Nation’s Biggest Private Plan”:
Dapite, Inc. is a planwide subsidiary which prepackages medicines and supplies them at bargain rates to the hospitals and clinics (whose doctors also agree to use mostly generic-named drugs, cheaper than the trademarked equivalents).
Northern Ireland pharmacist Margaret McClelland worked at Dapite for eight months in 1961, and wrote this account in the United Kingdom publication The Chemist and Druggist:
The Kaiser Foundation Hospital in Vallejo, where Dapite is situated, has a rehabilitation centre at which is operated a specialised technique perfected by Dr. Mead and Miss Knott (chief physiotherapist). Dapite, Inc., has, in the past, employed many disabled people from the Centre as part of its rehabilitation scheme. At the time of writing two such workers, victims of mining accidents, repackage drugs and two polio victims are on the office staff. Products manufactured by Dapite include x-ray solutions, pharmaceutical solutions, lotions, mixtures, ointments, eye preparations and disinfectants. Much of the work comprising repackaging of drugs in smaller quantities.
While I was at Dapite two young assistants carried out the heavier and “bulk” work — for example running alcohol from 40-gallon drums into l-gallon containers. Disinfectants, x-ray solutions, dextrose solutions, were put up similarly.
Orders were mailed in each morning by the various pharmacies or recorded on the telephone. Our day started at 7.30 a.m. when a hospital truck collected the orders and delivered them, providing a reasonably fast service within the 40-mile radius from Vallejo. The trend towards proprietary drugs I found even more marked in California than in Ireland.
In January 1963, the manufacture and wholesaling of drugs, previously conducted by Dapite, Inc., as a subsidiary of Kaiser Foundation Health Plan, was taken over by the department called Permanente Services, which centralized the competitive bid purchasing of virtually all supplies and equipment for Kaiser Permanente operations in Northern California. The KP Reporter described the transition:
At the same time Permanente Services took over the retail pharmacies at detached Medical Offices which had previously been operated by KF Health Plan. Purpose of these organizational changes, which do not affect the day-to-day functioning of the pharmacies, was to eliminate from the Health Plan structure any enterprise which might be considered commercial. The Dapite Company will be dissolved.
Today, Kaiser Permanente continues its efforts to address the high prices of prescription drugs by participating in public dialogue around the issue, advocating for our members and communities, and thus continuing the work we started in 1943 to reduce the cost of pharmaceuticals.
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Final essay in a series on Kaiser Permanente’s 70th anniversary
One of Kaiser Permanente’s key features is that it is an “Integrated health care system” – meaning it seamlessly provides care and coverage together and provides a wide range of services under one roof, whether in a Kaiser Permanente medical office or hospital or at a contracted facility. But in 1945 “integrated” also held another important meaning when the health plan was opened to the public – it reflected a deep commitment to being one of the first health care providers in the United States to have racially integrated hospitals and waiting rooms, as well as an ethnically diverse workforce, including physicians and allied health professionals.
During World War II, compliance with federal law (such as the Fair Employment Practice Committee) as well as decent best practices meant that employees were treated without institutional discrimination. An estimated 20,000 African Americans, along with many Chinese Americans, Native Americans, and Hispanic Americans, worked in the Kaiser shipyards. Kaiser Industries took great pride in this ethnic and racial diversity, featuring stories in the shipyard newsletters. A caption for a photo of an elegantly attired African-American female shipyard worker launching the Liberty ship S. Hall Young boasted: “How’s this, Adolf? It’s Richmond’s answer to your efforts to split America into warring racial groups.”
Industrial health care covered all workers, and the affordable supplemental health plan that Sidney Garfield, M.D. created for workers and their families in the Kaiser shipyards were equally open. In a time when the Civil Rights movement was just coalescing, racism in America was pervasive. Access to health care was no exception, yet the Permanente Foundation Hospitals took the high road.
Journalist Nick Bourne wrote about the Permanente Health Plan in the San Francisco News on October 7, 1943. He noted:
Illness knows no color line here. Red-helmeted men, women welders, Negroes lined up for a checkup by the busy young doctors. In one double room was Miss Katherine Rossi, shipyard loan office employee, here from Duluth, Minn., for six months; ill six months from skin trouble. A Negro woman was in the adjoining bed. “So help me!” declared Miss Rossi. “I’ve been in hospitals before, but never one like this. It’s sure swell. I don’t know what I would have done.”
The International Longshore and Warehouse Union newspaper The Dispatcher favorably remarked in 1945:
“The hospital’s facilities are open to all groups with no segregation of patients because of creed or color.”
In 1946, the year after the Health Plan was opened to the public, several local policemen visited the Oakland hospital with an eye to join. Permanente medical economist Avram Yedidia recalled the event:
“. . . The police chief said to me, ‘You know, when we walked through, I saw that you had some Negroes and whites in the same room. I don’t think we like that.’ “As I can recall, I responded, ‘Do you know this plan started that way, with blacks and whites in the shipyards, and that’s the way it goes. They worked together, and they were sick together.’ ” I told the police chief: ‘Those who don’t like it shouldn’t join the plan.’ ”
Diversity and inclusion continues to be a guiding principle at Kaiser Permanente. In 2013 Diversity Inc. magazine ranked Kaiser Permanente third in their “Top 50” national corporations, noting a workforce that at all levels reflects high percentages of women, Blacks, Latinos and Asians and has a diverse board of directors. This year Kaiser Permanente moved up to #2. Ronald Copeland, MD, Kaiser Permanente’s chief diversity and inclusion officer, recently affirmed the organization’s progress and challenge:
We must robustly, and in a systematic way, embrace multiculturalism and differences of our workforce and our member population to make sure that everybody’s meaningful needs are met in a personalized way…That is a journey we have been on for nearly 70 years and much progress has been made, but we still have a ways to go in order to become truly inclusive.
It’s about understanding and owning your own talents and vulnerabilities, and being comfortable and humble enough to share with and learn from others. It is about seeing and respecting the value in other people who are different than you and expecting them to do the same in return.
Over the past 70 years Kaiser Permanente’s commitment to nondiscrimination has moved well beyond race and ethnicity, to include gender, generation, sexual orientation, physical, and cognitive abilities in the pursuit of equality without exception. And, as a testament to the acceptance and support for such practices, 10 million people have chosen to “join the plan.”
Happy 70th anniversary, Kaiser Permanente.
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By Lincoln Cushing
Nathan Leonard (Len) Morgenstern, prominent physician, educator, (San Francisco) East Bay Area civic leader, and dedicated father and grandfather, passed away May 29 from head trauma following a fall. He was 91.
Dr. Morgenstern was a distinguished physician at the Kaiser Permanente Oakland Medical Center for 35 years, starting in 1954 and retiring in 1988 as chief of pathology. He authored several articles on cancer (including “Carcinoma of the Thyroid at Autopsy” in the AMA Archives of Internal Medicine, April 1, 1959), and taught as an adjunct professor of neuropathology at the University of California at San Francisco.
He was an active and beloved figure at the Oakland hospital, and over the years he took on many of the tasks that it takes to make a medical facility great.
A 1959 article in the employee newsletter KaiPermKapsul described how he conducted a training program for students who expected to make a career in pathology.
His one-year course in Medical Laboratory Technology was accredited by the AMA and the State of California, and affiliated with San Francisco State University, which gave credit for the work.
The article noted:
Rosario Bautista and Clyde James are among those receiving this thorough training in laboratory work, the former as an exchange student from the Philippines. Medical technologists in this state must all be licensed by the State Department of Public Health, following an examination.
Just to mention a few of the newer procedures they encounter in a Kaiser hospital laboratory: there are the microchemical analyses of blood, the assays on hormones, the tests on sensitivity of bacteria to various antibiotics, the investigation of allergic phenomena and use of new isotopes for the diagnosis and treatment of disease.
In many cases where the purpose of the test is the same, it is the method or equipment used which is the innovation. “Some of the procedures are complex and require very careful manipulation,” Dr. Morgenstern explained. “We try to adopt these as fast as we can satisfy ourselves of their worth. Where there’s doubt of the worth we may return to older, simpler methods. We rather incline toward the scientific caution ‘Don’t be first, and don’t be last’.”
In 1963, a Kaiser Permanente newsletter announced a research article he published in the medical journal Cancer, “Work with Doctors in Community” about early diagnosis and treatment of tumors in children, in collaboration with physicians from Kern County General Hospital, University of Southern California, and the Tumor Tissue Registry of the California Medical Association in Los Angeles.
A 1969 article touted the Oakland hospital’s School of Medical Technology, which had been in place for 20 years; as director of that program Dr. Morgenstern supervised the eight students — six women and two men. Each student in Oakland received a stipend of $3,600 for the year’s internship.
One of Dr. Morgenstern’s colleagues noted after his passing, “He always had time for teaching and clearly enjoyed it . . . He also had a great sense of humor and a wonderful kindness. He was a good man.”[i]
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[i] Dr. Art Levit, MD, comment in obituary memorial booklet.
by Lincoln Cushing, Heritage writer
In 1974 physicians at Kaiser Permanente Fontana (Calif.) Medical Center planted a most unusual garden at the center’s entrance. Behind a fence and locked gate they displayed 17 common poisonous plants found in homes and gardens, and called the collection the Sinister Garden – complete with a warning skull.
Pediatrician Guy Hartman, MD, (1922-2008) was concerned about the high number of local cases – as many as 300 in 1973 – that resulted from ingesting poisonous vegetation. “Children who are 4 years of age are our most frequent patients,” he told reporters. “This is the age of curiosity for these youngsters who are learning about their world by touching, feeling, and tasting just about everything.”
Dr. Hartman became interested in poisonous plants as a Boy Scout master in Southern California. “While working on a Scout project, we discovered that many common ornamental house and garden plants contain enough poison that, if accidentally eaten, could kill an entire family.” [i]
His garden was actively used for teaching. All plants were labeled and keyed to an exhibit sign explaining what the plants were named, which parts were poisonous, and what symptoms would occur if the plants were eaten. Busloads of children were brought to the garden to hear his warnings about castor beans, oleander, and wild mushrooms, to name a few. In 1976 the positive response led to the garden more than doubling in size, to 49 plants.
Around that time the pediatrics department produced a short video to broadcast the message, using a hand puppet named Amigo to charm the children. They also published a seven-page booklet, Welcome to the Sinister Garden.
In 1986 Kaiser Permanente’s Rockwood Clinic in Gresham, Oregon, installed its own garden, also as a response to local children’s poisonings. And in 1988, the physician-in-charge Thomas Hartman, MD, (no relation) planted a sinister garden at the old Bellflower (now Downey) service area at the Kaiser Permanente Imperial Medical Offices.
The garden in Fontana continues to be maintained and modernized, with landscape architecture students from nearby Cal Poly Pomona using it for design projects.
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by Lincoln Cushing, Heritage writer
Kaiser Permanente, and the practice of phobic medicine, lost a great leader this summer when Howard Barry Liebgold, MD, passed away at age 81.
Dr. Liebgold, who died August 15, got his undergraduate education at the University of California, Los Angeles and served his residency at the University of California San Francisco Medical Center (1956-1958) until earning his medical degree. He joined the Vallejo Kaiser Permanente Rehabilitation Center permanent staff as a rehabilitation physician in 1962.
During his tenure he served in many key capacities, including the chief of Kaiser Federation Rehabilitation Center, director of medical education at Vallejo, and chief of the chronic pain and acupuncture clinics.
Affectionately known as “Dr. Fear,” Dr. Liebgold was best known for 25 years of teaching classes and workshops about easing the painful restriction of phobic symptoms. Liebgold himself was severely phobic for more than three decades, but eventually developed a method of slow desensitization that worked. He called the resulting program Phobease, and wrote several books on the subject, including Curing Anxiety, Phobias, Shyness and Obsessive Compulsive Disorders (self-published, 1995). He helped to cure more than 10,000 people of their severe anxieties and Obsessive-Compulsive Disorders.
Dr. Liebgold also was an early proponent of acupuncture. In 1975 he received national media coverage for helping former Associate U.S. Supreme Court Justice Arthur J. Goldberg recover from an injured arm. Goldberg hailed the Vallejo center as “Most outstanding in the country.” Dr. Liebgold treated a thousand patients a year in addition to his inpatient rehabilitation work, and believed that acupuncture filled a very real need.
“I never embraced the Chinese philosophy. I was a Western physician. What I embraced was the Canadian belief, what they called the dry-needling technique, that this was purely a biomedical phenomenon. What acupuncture does is to produce micro-injuries and the healing of the micro-injuries also heals anything in the area.”[i]
Dr. Liebgold also embraced modern technology in the service of medical care. In 1964, he participated in a series of medical radio conferences that linked the University of California Medical Center with groups of practicing physicians from the Oregon border south to Bakersfield. The program, which was broadcast twice weekly, was conducted in a question-and-answer forum with participation from medical staff representing 70 California hospitals. According to Dr. Liebgold, this program provided the opportunity for small hospitals to have direct contact with the medical school and eminent specialists in various fields of medicine.
Dr. Liebgold represented the inquisitive mind and personal bravery that makes a doctor a true healer. He will be missed.
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[i] Unpublished interview by Steve Gilford, 1999 (TPMG P2853)
On the auspicious date of November 12, 2013 (10/12/13 for those into numerology) esteemed Kaiser Permanente physician and pioneer of medical informatics turned 100 years old. This event was celebrated at the St. Regis Hotel in San Francisco with The Collen Symposium: Looking Back to Look Forward. This one-day gathering hosted by the KP Division of Research drew scores of health care professionals, academics, researchers, and administrators to honor Dr. Collen’s contribution to the field.
Congratulations, Dr. Collen for your outstanding work.
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By Ginny McPartland
Fifth in a series
If the 1970s and 1980s brought a quality of care frenzy, circumstances in the 1990s conspired to create a veritable quality tsunami. Health care leaders reacted dramatically to a 1989 paper by industrial quality guru Donald Berwick and began to second guess health care reformers in Washington. Realizing their survival was at stake due to market pressures and government and employer demands for quality data, physicians and other health plan leaders dove head first into the quality quagmire.
Berwick’s message was revolutionary. His call to action was to take away the punitive side of quality review and bring all medical disciplines into a discussion of how to improve care processes and thus ensure better quality. Berwick’s influence was to abolish “The Theory of Bad Apples” in quality assurance and replace it with “The Theory of Continuous Improvement.”
Berwick, a physician in the Harvard Community Health Plan, had gotten his inspiration from Japanese industrial quality experts. Their carefully defined philosophy called “kaizen” led Japan to high quality factory production success. “An epigram captures this (Japanese) spirit: ‘Every defect is a treasure.’ In the discovery of imperfection lies the chance for processes to improve,” Berwick wrote in the New England Journal of Medicine Jan. 5, 1989 edition.
He adds: “Quality can be improved much more when people are assumed to be trying hard already, and are not accused of sloth. Fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to disaffection, distortion of information, and the loss of the chance to learn.”
Flawless care requires support for decisions
Physicians rely on a support system to carry out high quality health care, Berwick noted. “Flawless care requires not just sound decisions but also sound supports for those decisions . . . In hospitals, physicians both rely on and help shape almost every process pertaining to patients’ experiences, from support services, such as dietary and housekeeping, to clinical care services, such as laboratories and nursing. Few (processes) can improve without the help of the medical staff.”
Berwick urged significant investment in assessing and improving quality of care. “In other industries, quality improvement has yielded high dividends in cost reductions that may occur in health care as well. . . The most important investments of all are in education and study, to understand the complex production processes used in health care; we must understand them before we can improve them.”
With Berwick’s message ringing in their ears, Kaiser Permanente leaders jumped into high gear. In September of 1990, the Kaiser Permanente Committee embraced Berwick’s bold new approach, which had been dubbed “TQM,” for Total Quality Management. At the same time, the Joint Commission on Accreditation of Hospitals also adopted TQM principles in its reviews.
Vohs and Lawrence put force behind the Quality Agenda
The 1991 Annual Report, titled the Quest for Quality, was devoted to chronicling the TQM phenomenon and explaining its genesis and hope for the future. The report acknowledged the work done previously by pioneers Sam Sapin, MD, and Leonard Rubin, MD, but declared the need to step it up:
“The role of quality assurance historically has been to identify problems within the system,” explained Susan Leary, director of quality assurance in the Program Office. “But with TQM,” she says, “we’re given new empowerment to go out and get involved in the planning process and to make system-wide changes once those problems are identified.”
A 53-page binder produced at the launch of the Quality Agenda defined the campaign as “A Roadmap for the Future.” The guide was to speed up KP quality improvement efforts and to intensify efforts to share good ideas and innovations across the regions.
The campaign emphasized the need to get all employees to understand and take part in quality initiatives. The roadmap outlined five specific tasks: 1) creating of a positive work environment; 2) measuring what we do; 3) improving what we do; 4) developing new approaches; and 5) telling our story.
KP’s first program-wide Total Quality Management conference
In 1992, the first annual interregional conference on Total Quality Management featured workshops conducted by Don Berwick, MD; Brent James, MD, renowned quality improvement expert and statistician of Intermountain Healthcare in Utah; and David Eddy, MD, the man who invented the computer model that could compile a wide range of health data and simulate a realistic clinical situation.
Eddy was hired by the Southern California Permanente Medical Group in 1991 to use clinical research data to evaluate the benefits and harms of different clinical interventions. Eddy compiled actual patient outcomes and ascertained which treatment would likely bring the desired results.
“One treatment (for lower back pain) might have a 30 percent chance of returning a patient to work, while another has only a 10 percent chance,” Eddy said. “But the first treatment might have greater risks. How do we decide if the greatest benefits of the first treatment are worth the risk? To determine this, we’d like to ask patients what they prefer. They’re the ones who will live or die by these decisions.”
Physicians need help synthesizing complex medical research
In 1993, Lawrence published the Quality Agenda in Action, a report on quality initiatives across the program. Highlights included KP’s work with HMO groups and six large employers to develop the HEDIS (Health Employer Data and Information Set) quality measures and specific data collection methodologies for various treatments and preventive screenings.
The update also called out the Northern California Permanente Medical Group for its own launch of a program to establish best practices, vetted through research, and to implement and evaluate them. The Interregional Nursing Task Force brought together nurses from all regions to set up a system of best nursing practices.
A five-year study conducted by Southern California concluded that normal childbirth after a Caesarean section was possible and safe; while another study of 2.5 million patients in Northern California showed that screening for rectum and distal colon cancer with sigmoidoscopy decreased the rate of death from these conditions by 60 to 75 percent. In all, more than 350 TQM projects had been launched across KP’s 12 regions in the four years prior to the publication of Lawrence’s report.
Next time: How do physicians know they’re doing the right thing?
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 Edward J. Derbes
If Dr. Paul E. Stange had not attended medical school, he probably would have been a football coach, said his son, Paul V. Stange, who works as a policy analyst for the Centers for Disease Control.
Instead of coaching, though, Dr. Stange served as the physician-in-chief (PIC) at Kaiser Permanente’s Vallejo Medical Center for 22 years, one of the longest-term PICs in Kaiser Permanente history. But, his son added, those two career paths were not far off. That’s basically what he became: a head coach. He was a great leader (to the doctors). Firm, but fair.”
Dr. Stange passed away earlier this year on April 28. He was 90 years old.
At his retirement in 1991, his portrait was displayed in the lobby of the original Vallejo Medical Center, which was replaced with a new facility in 2010. His portrait remains near his former office in the old facility, which still houses administrative offices.
“That looks like an intelligent man and a superb leader,” Dr. Donald Nix recalls saying when he first saw the portrait. Dr. Nix was Dr. Stange’s best friend, colleague and long-time golf buddy. “I think those are the qualities that best describe Paul,” he added recently.
Career starts in left-over World War II barracks
Dr. Nix said that although Dr. Stange was their boss, the Vallejo doctors loved him. His two executive secretaries dubbed him “Mr. Wonderful.” When Dr. Stange began his tenure as PIC in 1965, the Vallejo Medical Center was housed in barracks-type buildings originally constructed for the Mare Island Shipyard war workers. His son, Paul, described them as rickety, green-finished wood buildings that Kaiser Permanente took over from the government when they opened a makeshift medical center in Vallejo right after World War II. Dr. Stange served through the construction of the $12 million, seven-story medical center, w hich was dedicated in 1973.
After stepping down as PIC, Dr. Stange continued his medical practice until 1991. He continued to lend his medical expertise by returning to the facility to give follow-up readings of radiology reports and mammograms. Maribel Guerrero, the breast care coordinator for Kaiser Permanente’s Napa-Solano Service Area, writes in gratitude to Dr. Stange in a 2006 letter: “The Kaiser Permanente organization should be proud to have you in its midst. . . . My job as breast care coordinator would not have been possible without your gracious help.”
Born in Milwaukee, Wisconsin, in 1921, Dr. Stange attended the University of Wisconsin School of Medicine during the mid-1940s. He served in the U.S. Navy from 1947 to 1951. After initially failing to get a residency in obstetrics, he completed a residency in pathology in Washington, D.C., in 1950. Three years later, he finished a residency in his preferred field, obstetrics, at the Kaiser Permanente Oakland Medical Center. Dr. Stange joined the Vallejo Medical Center’s OB/GYN department later in 1953.
Dr. Stange also had an active community life. He served on the board of directors for both the Vallejo Housing Authority and the Solano County Medical Society, which honored him with a lifetime achievement award in 1997.
Stange inspires two generations of medical professionals
Perhaps his greatest legacy to the medical community, though, is his family. Three of his daughters are registered nurses – Joan Pottenger, Gail Stange and Cynthia Stange-Zier. Another daughter, Susan Stange, works in patient care in Santa Rosa, California. And two of his grandsons are well on their way to becoming doctors; one of whom, Lucas Zier, recently received his medical degree from the University of California, San Francisco, where he is in his third year of residency for Internal Medicine. Brent says that Lucas plans to complete a cardiology fellowship next to finish up his training.
Brent C. Pottenger, another of Dr. Stange’s grandsons, will attend the Johns Hopkins University School of Medicine in the fall. He wrote the following essay about Paul E. Stange’s legacy, and how his grandfather influenced his decision to pursue a career in medicine.
Carrying on the tradition of physician leadership
By Brent C. Pottenger, MHA
From a hospital bed at Kaiser Permanente’s Vallejo Medical Center, where he served as a physician and leader for five decades, my grandfather, Dr. Paul E. Stange, first heard that I had been admitted to the Johns Hopkins University School of Medicine, often ranked the top medical school in the nation.
“Number one!” he proudly exclaimed when my mom, his daughter Joan Pottenger, herself a registered nurse for over thirty years, shared the news.
Upon hearing this story, I felt a responsibility to build upon his legacy of physician leadership; a legacy that, thankfully, my mom fostered in me by connecting her own experiences as a health care leader with memorable stories about my grandfather’s career.
My grandfather passed away at 90 years old on April 28, 2011. I decided to write this memorial essay for him not only because he inspired me to pursue a career in medicine, but also because of his dedication to managing the quality and cost of health care as a physician leader – a passion that ties in deeply with the legacy of Kaiser Permanente.
While I pursued a master of health administration degree at the University of Southern California, there was a primary question that drove my research: “Can physicians manage the quality and costs of health care?” The question is derived from Dr. John G. Smillie’s book, “Can Physicians Manage the Quality and Costs of Health Care: The Story of The Permanente Medical Group,” which traces the history of Kaiser Permanente. (The book also features a photo of my grandfather with fellow physician executives of The Permanente Medical Group sitting around a table during the early 1950s.)
In many ways, my grandfather has shown that, yes, physicians can help manage the quality and costs of health care. Throughout his career as PIC, for example, he constantly balanced budget constraints with optimal medical care delivery to provide the most effective health care services to Kaiser (Permanente) patients. After retiring, he also spent about five years leading the creation of a partnership program in Solano County that established a much-needed safety net for patients from underserved communities.
Building bridges defined my grandfather’s legacy – he constantly thought broadly about how to create partnerships that could benefit wider communities. Genuine efforts like those mentioned above capture his interest in health policy and administration considerations: Dr. Stange was passionate about Kaiser Permanente because he believed deeply in the tremendous value that its integrated health care system provides to patients. From prevention to efficiency, my grandfather’s personal values magnificently matched those of Kaiser Permanente.
At Johns Hopkins, I hope to build on my grandfather’s legacy to improve our health care systems. In an effort to combine lessons learned from both my grandfather and my mom, for example, I hope to found the Doctors-Nurses Alliance (DNA) at Hopkins to better integrate the medical training of our future clinicians. The DNA program at Hopkins would facilitate increased interaction between the medical students and the nursing students. I believe that Doctor-Nurse-Aligned teamwork forms the double-helix DNA of medical care delivery, so hopefully I can contribute to this cause during my medical training.
With projects like DNA, I plan on carrying with me throughout my career those inspirations that led to my grandfather’s steadfast dedication to Kaiser Permanente – his legacy inspires me to learn, serve, and lead.
*Edward J. Derbes is a 2010 graduate of the University of California, Berkeley (UCB), earning a bachelor’s degree in Rhetoric with High Distinction (Magna Cum Laude). He co-founded and was senior editor of Divergence Magazine of Cypress, California, and formerly served on the editorial staff of the College of Environmental Design e-News at UCB. Derbes grew up in New Orleans, Louisiana.
By Laura Thomas
First of two articles
Seventy-five years ago, two-thirds of American women gave birth at home with no painkillers, often attended by a family doctor, as the tradition of relying on midwives and practical nurses was falling away.
The practice of modern obstetrics was on the rise and the trend toward the majority of births occurring in hospitals was just around the corner as the American Medical Association met in Kansas City in May 1936 and hotly debated the benefits of new childbirth analgesics and how far to go in relieving the pain of childbirth.
According to Time Magazine, Dr. Gertrude Nielsen of Norman, Okla., denounced such pain killing innovations as twilight sleep – a combination of morphine and scopolamine – and a synergistic anesthesia accomplished by injecting a mixture of morphine and Epsom salts into the muscles and introducing a mix of quinine, alcohol and ether in olive oil into the rectum.
“An analgesic that is perfectly safe for both mother and child has not been discovered,” she told the convention. She asserted that fear of childbirth contributed to pain and called for prenatal education to reduce fear: “That is the modern physician’s duty.”
Part of the tumult over the issue had been provoked by articles in the press describing these new drugs and their use. Dr. Buford Garvin of Kansas City observed: “American obstetrics seems to be becoming a competitive practice to please American women in accordance with what they read in lay magazines.”
Childbirth trends change dramatically in the 1960s and 1970s
We could fast-forward to the 1950s when hospital childbirths had become the norm, the pain of the experience was reduced by epidural anesthesia and women relinquished control over the process to the physician. When Dr. Sidney Sharzer joined Permanente in Southern California in 1956, he became an early proponent of change.
During prenatal consultations Sharzer encouraged women to consider breastfeeding, advice which ran counter to the then-popular American pediatric practice of giving “modern” formula. At the University of Toronto, where he received his degree, breastfeeding was still considered preferable: “It provided early immunity and was just the right formula in that there were no problems with digestion and it was the right temperature,” he said.
Formula was seen as a convenience, especially for many women who remained in the workforce after World War II, and it allowed fathers to take part in infant care. It was also heavily promoted by the cereal companies who manufactured it. Most of Sharzer’s patients were bombarded “with a lot of propaganda, or advertising, as we call it,” he said, and resisted his advice. “If you bottle-fed, you were liberated. And, in those days, you were not going to whip out your breast at a shopping center.”
“Liberated” women demand natural childbirth
Ironically, it was the “liberated” women of a later era who demanded a more natural approach to childbirth and support for breastfeeding. Those whispers from the 1930s questioning drug use were getting louder.
“The mid-1960s and early 1970s saw a wholesale consumer revolt against highly structured, hospital-centered prenatal care,” Sharon Levine, MD, Northern California Permanente Medical Group executive, testified before a U.S. Senate committee in 1995. “Rooming in became commonplace. Home deliveries returned. Nurse midwives, who had all but disappeared from the American health system, became increasingly commonplace.
“Maternal-infant bonding became recognized as an essential part of postnatal care. Breastfeeding of infants made a dramatic resurgence,” she said in her testimony against a law to dictate length of hospital stay for new mothers.
Some innovation had already occurred at Kaiser Permanente. In the mid-1950s at Permanente founding physician Sidney Garfield’s behest, the “rooming-in” program began at new facilities in San Francisco, Walnut Creek and Los Angeles. In these early “dream hospitals,” the nursery had been built adjacent to the maternity rooms with slide-through drawers for the babies to be passed in from the nursery through a soundproof wall.
The baby-in-the-drawer configuration allowed a mother to pull the baby into her room to nurse and hold her child as long as she desired. “It keeps mother and baby closer together. Nurses are able to help the new mothers learn better how to care for their infants,” said a Kaiser Permanente newsletter of the era. Most hospitals of the time kept newborns separate from their mothers, under the care of the nursing staff, except for feeding times.
Bringing dad into delivery room
Around 1961, when he took over as chief of service at Harbor City Hospital, Sharzer made a couple of bold moves. He decided to bring fathers directly into the birthing room, and he began to encourage women to use the “prepared childbirth” techniques. He was inspired by British doctor Grantly Dick-Read’s book, “Childbirth without Fear,” which advocated the use of breathing techniques to minimize pain and increase the joy of the experience.
Lamaze breathing techniques were introduced in the U.S. by Marjorie Karmel after she gave birth in France assisted by Dr. Fernand Lamaze, who developed his techniques based on Dick-Read’s. She started an organization in 1960 – now Lamaze International – that currently focuses less on birthing methods and more on achieving a natural childbirth without drugs or technological intervention.
Sharzer remembers his struggle to get these ideas accepted: “The consumers were pushing for it and it was the right thing…husbands should see what their wives are going through.” At the time, fathers were ushered into a waiting room or went home to await a phone call and while some were thrilled to be invited to watch the process, others were less so. The nurses would good-naturedly chide a reluctant father. “They’d say he was a lousy husband to desert his wife at a time like this. They would appeal to his better nature and then insult him,” Sharzer said.
Outside of Harbor City, it was an uphill fight. When Sharzer first suggested the notion to his colleagues at the five other Permanente Southern California facilities, he was voted down 5 to 1. There was a lot of hostility from both doctors and nurses who assumed the fathers would try to get in the way by second guessing the medical staff, he said. But even their resistance couldn’t stop the forces of history. Fathers were finally allowed in delivery rooms at all Southern California facilities by the end of the 1960s.
Sharzer moved on to West Los Angeles in the 1970s and became assistant medical director: “It gave me the opportunity to be innovative.” There, he was able to inspire younger and more progressive doctors to go along with the trend toward treating childbirth as a natural process.
Natural birth after C-section?
Sharzer questioned the long-held “once a cesarean, always a cesarean” policy after he observed countless women scheduled for cesarean arrive at the hospital late in labor and give safe births. “If it’s that dangerous, how come these women come in and two minutes after they hit the bed, the baby comes out naturally?” he said.
Doctors feared that the vertical incision made through the large uterine muscle would rupture during contractions and for years women who had had a cesarean were discouraged from having subsequent vaginal births. But an innovation – the transverse incision made across the lower belly – was introduced that reduced the likelihood of rupture and more doctors began to experiment with allowing women to try vaginal births, under close monitoring.
A five-year study of vaginal births after cesarean deliveries in multiple hospitals showed that reverting to a natural birth process could be successful for many women. “Kaiser Permanente conducted the definitive study concluding that vaginal birth after a prior cesarean section is possible and safe … vaginal births are generally safer and less expensive for the mother and infant,” Permanente’s Dr. Levine told senators.*
Sharzer recalls: “A doctor had to be present all the time and there was a lot of resistance” among the general obstetrical crowd, but at Kaiser Permanente, vaginal birth after cesarean, known as VBAC, was easier to implement because a doctor was always on duty in the maternity ward. “In our setup, it was very good and we were one of the early ones to do VBAC.”
Nurse practitioners deliver prenatal care
In those years, Sharzer also helped establish the first program in Southern California for training nurse practitioners at Cal State Los Angeles and when they graduated, he hired them to work under supervision assisting the doctors with prenatal care.
Retired since 1993, after delivering some 7,000 babies at Harbor City and West Los Angeles, Sharzer attributes the tremendous change in maternity care since 1960 to the Civil Rights Act of 1964: “It also changed the philosophy of equality…and that applied to women in our society. It had a lot to do with female power.”
That piece of legislation guaranteed equal rights to women as well as African-Americans. But women, especially those active in the civil rights and anti-war movements, found themselves relegated to supportive roles to male leadership and many split off and created the feminist movement, founding the National Organization for Women, among others. Health care and childbirth became a major arena in women’s struggle for equality and power over their lives.
Next time: How Kaiser Permanente responded to member demands for shorter postpartum hospital stays.
*Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study. Obstet Gynecol 1990: 76(5 pt 1):750-4.