There have been a flurry of articles in the past months about more hospitals becoming insurers and more insurers also becoming providers. In most of the articles, there is a comment that these hospitals are trying to become fully integrated payer-providers just like Kaiser. No they are not. The payer provider model has been around US healthcare for a very long time, but the Kaiser twist on it is very wierd and as far as I know, no one else does it quite like Kaiser.
Kaiser is a fully integrated payer provider with exclusive usage. What does that mouthful mean? It means Kaiser owns its own hospitals, owns its own labs, owns it own rehab places, and 99% of the doctors that its members see will be employed and receiving a salary from Kaiser. It also has an insurance arm. This part is not too unusual. Geissenger in Pennsylvania is like that. Steward in Massachusetts is like that. Medstar in Washington/Baltimore is like that. Sutter Health in Northern California is becoming an integrated payer-provider. This part of the model is fairly common, and it is becoming even more common as the large hospital groups which are particpating in ACO experiments realize that they need the claims and predictive modeling capacity of an insurance company, so selling insurance is a short leap.
However, the unusual part of the Kaiser model is the exclusivity. Kaiser only allows its insured members to use its facilities and doctors for non-emergency care. If there was a major crisis, Kaiser would open its doors to a trauma stream but on a day to day basis if you are not insured by Kaiser and you need an ACL repair, you are not allowed into the Kaiser hospital four blocks from your house. If you have a heart attack, the ambulance will drop you off at the Kaiser facility four blocks from your house and Kaiser will stabilize you to the point where you are capable of transport and then ship you out. This part is extremely unusual.
Medstar in Washington D.C. owns Georgetown University hospital. GUH would go bankrupt if it only treated Medstar patients, so GUH takes Medstar insurance plus most if not all of the other major carriers who have a presence within 100 miles of Washington D.C. Vivity in Southern California has several world class medical centers. None of those centers could survive on the projected Vivity membership census. So Vivity member hospitals will take anyone who can pay. Geissenger hospitals will accept other major carriers as well. These organizations, and almost all other non-governmental payer-providers are not exclusive walled gardens that systemtically seek to minimize interaction with the entire US healthcare delivery ecosystem.
Kaiser is different.
The only comparable large scale delivery system in the United States is the Veterans Administration. The VA owns their own facilities, they own their own labs, they own their own rehab places, and they employ all their own docs. VA members have a few more options as they can go out of network and get private insurance, but the VA pays only when its covered vets get services at VA facilities by VA docs. I can not go to a VA hospital for anything despite the fact that the regional VA hospital is, depending on traffic, sometimes the hospital the least time away from my house.
So what does this difference mean?
Is it a distinction without a difference? I don’t think so. I think the Kaiser model allows it to capture and internalize significantly higher percentage of preventive and care coordination benefits than most other integrated payer provider models and far more benefits are captured than segregated payer/provider models. It allows for a common focus and a shared focus on quality and risk minimization as aligning incentives to pay docs to not order a needless test actually makes sense in all scenarios. Other integrated payer providers that are not exclusive walled gardens hvae the incentive to perform high quality and efficient care on their insured members but wasteful care on patients who are insured by someone else. A Sutter doc who orders an MRI on a non-best practice basis for a Sutter member is costing the company money, but ordering that MRI for an Anthem or United Health insured patient is a a revenue gain. Most providers don’t change their patterns of practice on a patient by patient basis, that means aggregate performance on minimizing needless tests, minimizing preventable care incidents is conflicted with revenue maximization.
Very few if any current integrated payer provider will move to the Kaiser exclusive walled garden strategy as the hurdles to clear are enormous. If there was a current large scale non-exclusive integrated payer-provider that wanted to go to an exclusive payer-provider model, it would face several massive risks. The first and greatest risk is losing the heads in beds count. Hospitals and other large scale medical facilities operate on a financial basis like Las Vegas hotels.
Hospitals and most other medical practices are the same way. Just opening the doors is extremely expensive as the fixed costs are very high. However, the marginal cost of treating the next patient for most situations (high end drug treatments excluded) are not that high. Hospitals with high census or heads in beds counts are able to use the high usage of their facilities to cover fixed costs and then operating costs.
Most of the major payer providers are based on general purpose hospitals or major academic medical centers. The operating margins are not excessive (3% to 8% per year) unlike specialty physician owned hospitals. Margins have been under pressure for years due to the combination of Sequester cuts, lower private reimbursement rates, fewer admissions, more CMS penalties for low quality care, and the proliferation of Medicare plus a kicker Exchange plans. Most hospital chains will see lower margins in the future. Moving to an exclusive model would mean that a significant portion of the daily treated population can no longer be treated at that hospital. This is a massive risk.
The two options of revenue replacement are to either convert those commercial members from other carriers into commercial members covered by the insurance side of the integrated payer-provider OR replacing other carrier commercial members with more government insured individuals (Medicaid and Medicare primarily). The problem with the first strategy is that conversion is a tough sell unless the hospitals in the newly exclusively payer-provider system have an amazing price, prestige and hopefully quality difference than the next best alternative. People don’t want to change their docs, they don’t want to be restricted in choices, they don’t want the hassle of switching carriers unless they absolutely detest the other available options. The problem with the second strategy is that Medicare and Medicaid tend to pay significantly less per service rendered than other private commercial insurance. There will be some groups who switch to maintain access to the regional high prestige but high cost hospital, but a system can not count on a mass conversion. Some of this will be counteracted by bringing current system members into the sytsem instead of having them receive servivces at other in-network hospitals and providers. The math is tough to make work over a five year conversion process.
The revenue risk is the biggest risk that will stop non-exclusive mostly open payer providers from converting to a Kaiser walled garden approach, so I don’t anticipate seeing full conversions. There have been some rumors and rumbles that there will be at least a few payer-providers will install significant gatekeepers and low walls for their network to keep most of their members in and other people out but the walls won’t be high nor hard to hop over.
Kaiser is wierd in the American context, and I anticipate it will continue to be an unusual but highly successful implementation of a fairly unique non-governmental model.
esc
My family had Kaiser before we left California. Before that, we had Tricare, so being in a walled garden was familiar to us and we couldn’t have kept our old providers anyway. I am not pumped, to say the least, about being out in the world of regular insurance. The in network vs out of network and pre approval thing gives me a lot of anxiety, especially seeing some of what my parents have gone through with their (admittedly horrible) insurance.
JPL
I turned medicare age in July and chose Blue Cross. My ex and I are legally separated which allowed me to keep his insurance. Although Kaiser is a tad more expensive, I’m thinking about making the switch. It’s one of the highest rated medicare provider in GA.
Kaiser is not an option through his former employer but their model works for me.
Steeplejack
I went with Kaiser when I signed up for Obamacare earlier this year. I like their philosophy. Haven’t had occasion to use the services yet (thank goodness). That reminds me: I do need to call and set up a physical.
Richard Mayhew
@Steeplejack: Always a good thing… I like Kaiser as well from an operational standpoint, they do great on NCQA quality rankings. I just have a hard time seeing other top tier plans going full Kaiser. The membership fall-off risk is massive.
C.V. Danes
Jeeze, if only we could just take the Kaiser plan and extend it across the entire country, you know, like single payer…
Wait, what am I thinking? Freedum!
Sorry for the lapse.
Woodrowfan
I had Kaiser twenty years ago. I hated it. Never saw the same doctor twice and felt like I was being rushed through everything. That was a long time ago though, maybe it’s gotten better.
Roger Moore
I think the big difference with Kaiser is that they’ve been doing things their way since WWII, so they’ve had plenty of time to get their system built into an actual system and adjust the size of their health care network to the size of their health insurance network. I assume this is also a reason they aren’t in every market; they really have to jump in with both feet to get their system set up in a new area.
theo
One thing you didn’t mention is their IT and medical records systems which are excellent at least relative to medical providers. Because everyone is in the walled garden, they have access to full treatment history (and utilize it) whereas if they had external patients, they would have to take imperfect case histories all the damn time.
It’s actually the main reason I’m with Kaiser — I don’t trust other providers to coordinate care correctly without a decent IT system. I don’t know that their rate of medical errors is lower, but I’d be surprised if it wasn’t.
Steeplejack
@Richard Mayhew:
I don’t think it is practical for other companies to switch to a Kaiser-style plan. It sort of has to grow organically, in a sense. My understanding is that Kaiser (the original construction company) had a small, sort-of-HMO-like thing going as far back as the ’30s, and the plan ballooned along with the company during the massive industrial surge of World War II.
Jager
The last company provided health insurance I had was California Blue Cross (Anthem) they were a joke. $20,00 copay on a generic drug that cost $8.00. (the pharmacist at CVS tipped me off)
When I started Medicare my Kaiser Doc neighbor suggested I sign up with them for my Medicare Supplement, $6.00 a month, choice of docs in my area. I have a clinic 10 minutes from my house and a major Kaiser Hospital 25 minutes away. The electronic record keeping is dynamite, I can go on line and review anything and everything. The tests are cheap, the drugs are cheap, the staff is great and so are the facilities. Best health care I’ve ever had. BTW I had a blood test a few weeks ago, left the clinic, met my wife, went out to dinner and when I got home I had the results in my e-mail. They are the best.
Wag
Kaiser is a really excellent choice for health care, and I say that as a provider in a competing network here in Denver. That said, Richard, your description of the exclusive kaiser hospital may be a market specific necessity. Here in Denver Kaiser members must use hospitals in the Exempla network, but Kaiser patients only make up about half of Exempla’s business.
RP
I live in DC and have Kaiser. I love it. It’s efficient and reasonably priced, and I’ve liked all of the doctors I’ve seen. Unfortunately, my employer is dropping the plan and I have to switch to UnitedHealth at the end of the year, and everyone in the office seems to hate United.
srv
Kaiser was in those 18 minutes
I think the Kaiser experience boils down to the doctor you have, as it does everywhere. My doc just retired so will be finding out.
Amir Khalid
For a moment there, I thought you meant this guy.
Frances Perkins
My husband and I have been with Kaiser for many years. They are absolutely wonderful.
Rand Careaga
I’ve been covered by Kaiser since 1977. It used to be fantastically affordable, but grew gradually less so over the decades and steeply less in recent years: my annual premium (“self and family” — actually just “self and spouse”) has gone from approximately $2200 per annum seven years ago to $7150 today, with out-of-pocket costs also going substantially higher during the same period. My wages have not seen commensurate growth. Could it be that they’ve recruited some former Enron executives to serve on the Board of Directors?
I will say that I have no complaints about the level of care provided, although in my experience it helps greatly to bail on your primary physician if her or she isn’t simpatico. I once had a doctor who felt that she was letting Kaiser down if our encounters ran over five minutes. They wound up promoting her to management, I believe.
kindness
@Roger Moore: I work for Kaiser so this point of view has it’s own baggage. Kaiser can’t be in every market. It doesn’t want to be. Building a system like they have is very expensive. It requires a service population that is larger than any rural area could provide.
Here in N. Cal, Kaiser opened a new unit out in the Central Valley 10 years ago and ran it like a Blue Cross. Everything was contracted. They had intended to build up their own system/campus and at this point they have. But it was a difficult transition and was way more expensive than was originally envisioned. Doubt they’ll try it again. Kaiser works best in it’s own system. That is where one can realize cost savings.
Single payer if it ever comes will look like Kaiser though. For the record, I wanted Single Payer even though it would have put me out of a job I really like.
CONGRATULATIONS!
I’ve been with Kaiser SoCal for a decade now. I am, put nicely, not happy. The quality of their care is very uneven at best.
Last visit I heard my doctor and nurse outside my door betting that he could get through my appointment in two and a half minutes. For a serious hand injury, no less.
At least it’s not Kaiser NorCal. That is a thoroughly awful system from admission to discharge.
If this is the model for single payer, as some others above have suggested, fuck that.
? Martin
Another Kaiser customer and we love them. Yes, much depends on the doctor you have but we’ve been through many doctors in many specialty areas and only twice have asked to change doctors. The doctors we’ve had meta conversations with have all indicated that they like working there – most of the administration is eliminated, they earn a decent (though not exceptional) salary and get to be doctors 90% of their day. So I think it attracts a high quality pool of professionals. And I’ve never gotten the sense they were trying to save money on treatment. When my son was having trouble with a procedure that is normally done in the doctors office due to a phobia, they were quick to suggest moving to an operating setting where they could better work around the phobia. Even that took 3 attempts before he could go through it (we were getting him treatment for the phobia but that’s a slow process), and they were infinitely patient with us. They have also been quick to outsource when appropriate and we’ve been sent to CHOC (childrens hospital) for specialized issues with the kids.
We have a clinic walking distance from the house and that’s where our GP is. We have a hospital a mile from the house, also walking/biking distance. We’ve never seen a bill or any financial paperwork to do. Their EMR seems to be excellent. We’ve visited 3 of their hospitals, several urgent cares, and at least a dozen other facilities and they always know what’s going on.
There’s not a lot to object to from our perspective.
canegiallo
@Woodrowfan: I’ve had very good experiences with Kaiser. We had it when the kids were growing up and they saved us a few ER visits. My mother had Kaiser Advantage for her Medicare and her doctor was always patient and caring. My mother’s last illness involved two hospitals (neither of which was a Kaiser hospital), neurosurgery, more than a week in intensive care and additional step down care days. The only bill I ever got was for the ambulance ride to the first hospital. I’ve chosen Kaiser for my Medicare. In the Mid-Atlantic region they don’t own the hospitals but have special arrangements with several hospitals and have Kaiser dedicated hospitalists working at each of those hosptials (all of which are non-profit, I believe). They have extensive after hours and a couple of centers in the county with 24/7 urgent care.
I do not feel rushed at all when I see my doctor at Kaiser and I’ve had the same one for a number of years now (I had Kaiser before I retired, too). I’ve never had a problem getting a recommendation to a specialist and the drugs are uniformly a $3.00 co-pay. I recommend Kaiser to everyone, unless you have a personal relationship with a particular physician.
kindness
@CONGRATULATIONS!: Bullshit.
Kaiser here in Northern California gets very high marks from it’s members.
CONGRATULATIONS!
@kindness: I’m sure that’s true. However, the member ratings system is bullshit: they only send out ratings forms to patients who they already know have had a good experience. I’ve been with them long enough to know. 5 years in the Bay Area and 12 here in SoCal. Kaiser’s member satisfaction ratings are complete and total fiction. Their enrollment is high not because they are awesome, but because frequently they are the only insurance small employers can get for their employees.
Having seen the miserable excuse that passed for post-incident care with my mother-in-law’s stroke, and the equally awful post-op care doled out to my wife, I can very confidently say that I’d rather take my chances at Laguna Honda or SF General than fall into the clutches of Kaiser NorCal. They are good at dealing with immediate issues. Their follow-up care would be utterly unacceptable in a vet clinic.
Roger Moore
@kindness:
At least the ones who don’t need kidney transplants.
Avery Greynold
If you are not used to a system that minimizes health care provided (Kaiser), you may not realize that you have to push to see specialists. The specialists are very good, but can seem to be walled off by primary care providers. They give you meds, send you home, and hope you won’t need more. Sounds like Dallas, but isn’t.
Roger Moore
@kindness:
I’m not sure if that’s completely true. Kaiser does operate a lot of smaller satellite offices that don’t offer the full range of services you get in a full-scale hospital, and they could adapt something like that to a low density rural area. They would need to be the dominant provider for that to work well, but they could do it. The really hard part would be transitioning from not being represented there at all to being the dominant provider. It would involve either operating at a loss for quite a while or buying out an existing provider.
I think they’ll probably continue trying to expand into new markets because providing care is really part of their mission. They will probably concentrate more on expanding into areas adjacent to places they’re already serving, since they can take advantage of their existing facilities. It’s the most natural way for them to grow, but they may continue to try breaking into completely new markets.
Single payer is actually more like Medicare, where the government pays for the insurance, but services are still provided by a whole array of private providers. The integrated payer-provider model is more like a National Health Service, where the government runs the clinics and hospitals, too. Unsurprisingly, NHS-type service seems to give the most bang for the buck.
Lizzy L
I’ve been a member of Kaiser NorCal (San Francisco, and then Richmond & Pinole) since 1972. It has weaknesses, certainly, but so does every large hospital system. The major stuff they have treated me for includes a broken leg and a heart attack, and they did a superb job. They push preventative care, which is generally a social good (vaccines, flu shots, mammograms, etc) and they offer all kinds of programs such as support for new diabetics, support for abuse victims, well baby clinics, and so on. Are they perfect? Hell, no. As has been pointed out, you have to really push to see a specialist, and it’s hard to really push when you are very, very sick. But their record keeping is excellent, I can e-mail my doctor and get an answer in 48 hours (usually within 12), I can refill drugs and make appointments online, and their Advice Nurse is a phone call away.
Richard Mayhew
@kindness: Geissenger does very well in rural Pennsylvania, it is not fully exclusive payer-provider, but that model is not neccessarily population density dependent.
Richard Mayhew
@Wag: Kaiser fully integrated exclusive payer-provider model is most notable on the West Coast, their eastern expansions are more of a mixed model.
JaneE
Kaiser started its model during WWII, out of necessity. When the Kaiser Steel plant was built in Fontana, CA to meet the govt’s need for steel for the war effort, there was nothing there. Including doctors. In order to get experienced steel workers to move from the East coast, part of the package was an on site hospital and all the medical staff and facilities to meet the medical needs of the employees and their families. At the time Kaiser Steel had at least 8000 employees. Kaiser built the hospital at the plant and hired everyone they needed to operate it and provide any needed care to thousands of people, pretty much from day one.
Tree With Water
Thanks for that explanation that, Mayhew. Over the years I’ve questioned different persons about what it is that serves to differentiate Kaiser’s business model from others, and never received a satisfactory answer. Now, I sort of get it.
Arclite
@Woodrowfan:
I had Kaiser up until 5 years ago. Had a GP that I’d chosen and always saw her. When I had my thyroid problems, I always saw the same endocronologist, and for my surgery the same ENT. I think they realized people needed that stability. It’s been in their advertising for a while.
I got good care from them, and liked their system. They have a bunch of hospitals and clinics all over Oahu, so it was never a problem. They were cheaper by about $10 per month, which was only 3-4%. My co-pay was a few dollars cheaper than if I wasn’t on Kaiser. I would have thought they’d be cheaper than that given that they’re both non-profit and using their walled garden as a kind of mini single-payer system. But it wasn’t really that different.
Julie
And potentially the biggest problem with their model. I think they’re great on general healthcare-type stuff, but I’ve heard enough stories (via a family and friend network full of EMS-types) about their emergency protocols to give me pause. Aka, “Oh that heart attack’s not *that* bad. We’ll send you to our facility overnight and then you can see one of our surgeons the morning…” where the person would have been dead by morning if not for some pretty aggressive intervention by non-Kaiser medical personnel on the scene.
Tommy Dee
We’re on Medicare thru Kaiser and it’s pretty darn good. They’re very aggressive about preventive care and fixing things before they get expensive. For instance, at every visit one is asked how much exercise, how much alcohol, what meds yr using. Kaiser runs drive-thru flu shot clinics — pull up, roll the window down, get the shot, drive away. If I don’t renew my vaccinations on time they call me up. Same with an annual physical. All this works for Kaiser, I’m sure, and works for me too.
For the record, the docs don’t exactly work for Kaiser. There’s a separate physicians group that contracts exclusively with Kaiser itself. I assume this means the docs have leverage about patient load and so forth that direct hires wouldn’t.
Shirt
My personal experience with Kaiser was pretty bad. Under 40 siconvallyite They could not fix even a (chronically) bloody nose. Always assessed me as a druggie and dismissed my hypertension as due to drug use. Their assessments where absolutely inaccurate. OTOH…
My family’s experience was wonderful. Above and beyond that of any hospital near Newport Beach. My mother came by ambulance from her assisted living home (she was/is 90!) because of clear cardio symptoms. Kaiser was the closest so they took her. Assessed her; figured out what was going on and stabilized her. Kept her for two days to make sure she was stable. Then they assigned an assisted living case worker who told us (as we suspected) the home she was in could not really support an urgent needs that might arise. They got my mom into a home which is 20 miles closer to all her offspring for the same cost with superior medical staff and visiting doctors. And the cost? Paid for by Medicare and AARP.
Wowser!
Mnemosyne
@Shirt:
This is probably why:
siliconvalleyite
vs.
Newport Beach
Apologies to kindness, but I have heard WAY more complaints (and more serious ones) about Kaiser Northern California than Southern California. I was with Kaiser for a long time, but my prescriptions became too much of a pain in the butt (mostly due to my company’s policies, come to find out), so I switched to Cigna.
James Barnett
@Woodrowfan:
On the other hand, I had to quit Kaiser after 11 years when I switched jobs. 6 years later, when my new job finally offered Kaiser and I joined up again, I got the same primary care physician I had before … AND HE REMEMBERED ME.
Elizabelle
Thank you all for your comments. I am signing up for Obamacare, or at least healthcare, this round. KP is one of our options in Virginia (which did not build its own health exchange — thanks convicted Governor Transvaginal Bob — or expand Medicaid — thanks gerrymandered GOP legislature, and may that come back to haunt you in future years).
Still more expensive than I’d prefer, but need to sign up. Have been lucky so far, but it’s too much risk to go without insurance.
There’s a Kaiser facility maybe 5 miles from my home. Will head over there and see if they have an enrollment specialist who can help me choose the right plan.
Just Some Fuckhead
This isn’t unusual. In our area, Sentara Hospitals owns Optima Insurance.
parsimon
@Lizzy L: Are they perfect? Hell, no. As has been pointed out, you have to really push to see a specialist
This is a problem. I can’t tell you what I went through a year or so ago (on a Blue Cross plan) to get my surprising allergic skin reaction to penicillin treated. First to my GP, of course. Then to an allergy specialist, who told me to give it more time to work itself out. Since the reaction had gone on for nearly at month at that point, that was not viable, indeed stupid. Finally I decided to take myself off to a dermatologist — magic help! I had to determine what sort of specialist to see myself. Without the freedom of a plan that allows me to do that, I’d be furious, as well as falling apart at the seams, to be honest. It was not a situation that allowed for gated coverage.
amy c
We had Kaiser for a stretch when we lived in Northern Virginia. We mostly loved it.
For my husband and me, the technology was the best part. We could (and did) schedule appointments online, access medical records online, and email our doctor for non-urgent issues. And the doctor actually emailed back! Plus, every doctor you’d see would have the same comprehensive records in the same format – no more filling out reams of paper forms, no more answering the same questions over and over again for each specialist.
Of course, none of this would have been worth it if the care was lousy, but we were happy with it. The doctors weren’t markedly better or worse than any others I’ve seen. And you’re totally free to choose another Kaiser doctor if you get one you’re not happy with.
It was never a problem to get a short-notice appointment, either – at least for primary care and pediatricians. When I moved to a new state last year, no longer with Kaiser, it took me weeks to find a primary care physician who was taking new patients at all. And once I finally did find one, the soonest appointment I could get for a physical was *eight months* down the road. That sort of thing didn’t happen with Kaiser.
I also loved that during the whole time we were with Kaiser, we never got socked with a bill we didn’t expect. Even when we were referred to a specialist who worked at Children’s Hospital and wasn’t part of the Kaiser system (and yes, can do this, though obviously they don’t make a habit of it) everything was covered as expected. Sure, we had co-pays, but none of that nonsense where you do what your doctor says like a good patient and find yourself burdened with an indecipherable $1,500 invoice in your mailbox three days later.
Downsides of Kaiser? The wait at the pharmacy was often long enough to be vaguely annoying, and I didn’t love how quickly they sent my son home after his tonsillectomy (though they did fine on the surgery itself, and his pediatrician was great in the follow-up).
pseudonymous in nc
@CONGRATULATIONS!:
It’s not, and fuck that. When the network is the nation (or if you prefer, the state) and the reimbursement rate is set that broadly, then you don’t get assembly-line medicine.
pseudonymous in nc
@Avery Greynold:
The ideal healthcare system is the one that doesn’t have any financial incentive to load you into the Magic MRI Machine, or where you don’t need to jump to a specialist for diagnostic stuff, but where there’s a relatively straightforward path to specialist stuff.
That requires good and well-paid general practitioners, but also slightly less well-paid specialists. Tricky to get from here to there in the US.
dianne
I had a rocky start with Kaiser because I didn’t like my primary physician. He was aloof and seemed to be just punching the clock. He retired and I was assigned a primary who is bright and is an advocate for his patients.
The primary is key. I have never had a sense that he is a cost cutter. He will send us to a specialist at the drop of a hat and for the slightest of reasons. Sometimes I get annoyed and feel over doctored but the alternative is much worse.
I didn’t realize back when that you can easily ask for a change of primary so do be assertive if the fit isn’t right.
Nathanael
In what sense is Kaiser a non-governmental model? It’s essentially a private, unaccountable government.
If your workplace uses Kaiser, you are at the mercy of Kaiser nearly as much as you are at the mercy of the local police force. You are *under the power* of Kaiser. It’s a government.
Cranky Observer
In the 1982 – 1988 time period the then Michael Reese Hospital / Health Care attempted to implement a Kaiser-type fully internal HMO in Chicago and the Chicago metropolitan area. I was a subscriber during that period and it worked very well for me. The ultimate result however was that both the HMO and ultimately the parent company went bankrupt. In the oughts I had occasion to make use of Kaiser services when working on assignment in Cali; again I found their system to work well (and I believe they are now expanding outside of California). Why this system seems to work well in southern CA but nowhere else is to me an important question, but not one I can imagine any medical industry research org funding.