External Affairs

 
On my first day at Kaiser Permanente (KP) in 1979, my boss put me in a windowless room at the old KP Southern California Regional Offices on Sunset Boulevard with a stack of news clippings. "Read these," she said through puffs of smoke from her ubiquitous cigarette. "You'll get an idea of what we're all about."

The clippings proved to be quite a collection! By far the greatest number were about this wonderful new idea--the health maintenance organization, or HMO--exemplified by KP. Health care would be revolutionized by giving doctors the incentive to provide only medically necessary care--thus eliminating dangerous and costly overtreatment.

What Has Changed--And Why
A lot has changed since the day I first read those articles. For one thing, bosses can't blow smoke in your office. More critically, however, the landscape for HMOs has changed dramatically. Incentives that once were hailed as the savior of health care are now derided as being the devil incarnate--an invitation to deny necessary care in the interest of a better bottom line.

What happened, of course, was that the favorable press HMOs were receiving brought into the market a substantial number of profiteers who may have seen big bucks in the health care business. By pressuring doctors and hospitals (whose gluttony, they might have reasoned, was the cause of the problem in the first place), such for-profit HMOs could provide health care to beleaguered corporations, some of whom were spending more on health insurance for their employees than on raw materials for their products.

But the for-profit HMOs underestimated the strategic intelligence of organized medicine. Doctors--who had been considered the villains--successfully recast themselves as the victims. Doctors convinced their patients that they (ie, doctors) were being dangerously constrained in their ability to give patients the health care they needed. That technique attracted the attention of the press, and responses from the press attracted the attention of politicians who were on the lookout for a crowdpleasing, votegetting issue.

Despite the fact that most people are generally satisfied with their own health plans, the credibility of HMOs dropped to the bottom of the list of favorite vendors--along with used car salesmen and tobacco companies. Humphrey Taylor, chairman of the recent Harris Poll--which showed that nearly seven of ten Americans give their health plans an "A" or "B" grade--said that "deteriorating public perceptions of managed care are media-driven, or physician-driven, not experience-driven."^1:2

In the meantime, KP continued at its slow and steady pace. Most certainly, we thought, people knew us and trusted us and would never accuse us of the kind of perfidy for which they held our forprofit competition accountable. We were, after all, different: We were Kaiser Permanente.

But we had no such luck; we ended up tarred with the same brush as the rest of the health care industry. Nonetheless, we had endured criticism before and had survived. Why would this newest episode be any different?

The Criticism
T he difference, I think, has been the nature of the criticism. Looking back over the more than two decades I've been doing public relations for Kaiser Permanente, I've seen the type of criticism change dramatically. When I started, critics questioned our capability:

• Could we provide the same quality of medicine as the "private practice" doctors and highprofile hospitals?
• Could we create systems that would provide easy and convenient access without frustratingly long waits?
• Could we really provide quality care at lower cost?

Some critics thought we had difficulty delivering on our promises--but they felt we were sincere, if sometimes a bit clumsy.

In recent years, the tone of the questions has changed. Although our capability is still sometimes challenged, even our most persistent critics have acknowledged that the care we provide is above reproach. However, the backlash of criticism for managed care has led those same critics to raise questions about our integrity--our willingness to offer to members the care we are capable of providing. Questions now changed from "could" to "would":

• Would we continue to provide quality care even if it were more expensive?
• Would we improve our systems to improve the hassle of getting to see the doctor?
• Would we be there for the member whose life threatening illness required costly treatment?

This is the greatest challenge of all. Given the choice, I'd rather be thought a fool than a scoundrel: Fools can learn, but scoundrels rarely repent.

Our Current Task: Promote Integrity
Our challenge, then, is to protect our reputation for integrity as well as capability. We've long worked the capability side of the street by publicizing our research, our clinical excellence, our many awards and honors. And, of course, we have defended ourselves when critics assailed the quality of care we delivered.

The need now is to do what we never thought we'd have to do: defend and promote our integrity.

On the public relations front, we do this by promoting KP's patient-friendly policies and practices as well as our many community service activities.

We take every opportunity to explain that group capitation takes physician incentives out of the examination room and puts them into the committee room, where groups of doctors look for ways to improve the effectiveness and efficiency of the care they deliver, thereby eliminating the high cost of delivering poor-quality care. We recently received a substantial public relations boost from the PBS program "Critical Condition," which accurately portrayed us as being an organization driven primarily by the core values of clinical quality and member benefit.

It's an ongoing battle, however. When controversies erupt--as they did over the practice of "pill-splitting"--our critics tend to immediately assume that we're sacrificing quality on the altar of profit. They assume that our motivation is solely monetary. Our critics never stop to consider that we never act unless we are first convinced that a practice is safe and that keeping health care affordable is in the best interests of our members and the public whom the critics profess to serve.

Community Service Activities
We will continue to reinforce the underlying messages about our core values and to promote our clinical quality whenever we talk with external and internal audiences. Supporting community service activities and advocating for sound public health care policy are other avenues for demonstrating our commitment to the public good.

Permanente physicians also have a key role as guardians of our reputation. You can help in the following ways:

Help us tell our story: We bolster our reputation most effectively by showcasing the work of our doctors--whether in clinical practice, in research, or in community work. Let your Public Affairs Department know when you are involved in something noteworthy, and be willing to work with them if they ask you to participate in a press interview.

Talk to your patients: Our own members are our most important ambassadors, and their opinions are shaped to a great extent by their contact with you. Time and appropriateness permitting, answer their questions about the way in which health care decisions are made at KP. Let members know that, unlike independent physicians who contract with multiple HMOs, your incentives come from the way your whole group functions. Particularly when you are in the position of recommending against a particular treatment, help them understand that your medical decisions are based on their health care needs--not our financial needs.

Join local medical associations: The personal and professional relationships you can develop by joining your local medical association help to leverage the influence of the medical community in our favor. There is no greater testament to our trustworthiness than to have the medical community acknowledge that we operate in a manner that puts patients first.

Volunteer: Studies have shown that an organization's reputation is most positively affected by encounters with individuals in that organization, whether on the job or off. Haven't you occasionally based your view of an organization on your personal knowledge of one of its members? Meeting someone who is volunteering for a cause important to you is doubly impressive. Your local Public Affairs Department can connect you with an appropriate community activity.

Write Letters to the Editor: Whenever you see HMOs being maligned in the press, pick up a pen (or sit down at your computer) and let people know that your experience at KP is different. The most important point we have to make--over and over--is that KP physicians have complete authority to make independent decisions about medical care for their patients. This independence is a core issue for many people. Their trust in us is enhanced when they know that, at KP, health care is "in the hands of doctors." (If you'd like to be part of a network of physicians who are kept apprised of media activity, contact Beverly Hayon at 510-271-6437.)

Fight to maintain integrity: We're not perfect. Speak out when you feel uncomfortable with a decision or with a change in practice that you think compromises quality. Make sure that we have a good story to tell.

References
1. Taylor H. Most people continue to think well of their health plans. Harris Poll 2001 Jan 10;3:1-2.

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