As a nonprofit community service organization dedicated
to improving the health of the communities we serve, Kaiser Permanente
(KP) understands that our role extends beyond providing health
care to our members: Our social mission leads us to serve the
health care needs of the greater communities.
Historical and Current Funding
Historically, graduate medical education itself has been recognized
as a community service and is therefore entitled to receive Medicare
funding. In fact, Medicare has been a major source of funding
for graduate medical education since the mid-1960s. Until 1983,
Medicare paid for graduate medical education on a cost-reimbursement
basis. With the enactment of the Consolidated Budget Reconciliation
Act of 1985 (COBRA), Medicare replaced its cost-based funding
formula with two types of discrete payments: direct medical education
(DME) payments and indirect medical education (IME) adjustments.
DME payments are intended to defray administrative costs associated
with residency programs, and IME adjustments are intended to defray
costs associated with the higher rates of morbidity associated
with teaching hospitals and with the inefficiency inherent in
teaching situations.
In the past, Medicare's payment to health maintenance organizations
(HMOs) was based on adjusted average per capita cost (AAPCC) for
Medicare beneficiaries in the fee-for-service sector. Before the
1997 budget reconciliation agreement took effect, health plans
received revenue for patient care provided by residents and by
their sponsoring institutions. Academic teaching hospitals have
historically been critical of HMOs not directly engaged in graduate
medical education, because these HMOs benefited from the AAPCC
formula despite not actually educating residents. The 1997 budget
reconciliation act encourages training in ambulatory settings
by expanding eligibility for DME and IME at such sites; HMOs will
no longer receive DME and IME payments through the AAPCC unless
they actually participate in graduate medical education.
Direct Community Benefit Investment
The Southern California Permanente Medical Group (SCPMG) currently
trains nearly 300 residents at Kaiser Permanente (KP) facilities
and interacts with a comparable number of residents from other
sponsoring institutions. Funding for residency education is provided
through the Community Affairs Budget and is administered by the
SCPMG Clinical Services Department. Beginning with the fiscal
year 2000, evidence of direct community benefit investment (DCBI)
will be a prerequisite for all funding. Under current federal
statutes, graduate medical education qualifies as a community
service; therefore, this education is entitled to receive tax
benefits and Medicare support.
In 1994, the California state legislature passed Senate Bill
697, which required all not-for-profit hospitals in California
to assess community needs as a basis for developing a community
benefit plan. SCPMG partnered with United Way to conduct our community
needs assessment because of United Way's approach to community
building: United Way works with the community to identify its
unmet needs and targets philanthropic dollars and resources to
build the community's capacity to achieve greater health and wellbeing.
Volunteer activities at both Los Angeles Free Clinic and Venice
Family Clinic were included in the Metropolitan Los Angeles Community
Benefit Action Plan.
The Free Clinics
The Los Angeles Free Clinic has been providing medical, dental,
and legal services to uninsured people in the Hollywood area since
the late 1960s. The Clinic now operates at two sites: one site
provides comprehensive services, and the other site is dedicated
to providing care for high-risk teenagers. Similarly, Venice Family
Clinic has been serving the homeless, the medically underserved,
and the working poor in the Westside communities of Los Angeles,
Santa Monica, and Venice since the early 1970s. As a result of
the Los Angeles County budget crisis, Venice Family Clinic expanded
its services from the original Venice site to two facilities formerly
associated with Los Angeles County: the Burke Health Center in
Santa Monica and the Los Angeles County Venice Health Center.
In recognition of its outstanding service to these communities,
the Venice Family Clinic was recognized with the prestigious Presidential
Volunteer Action Award in 1996.
"Why Doctor Hara is a Lousy Golfer"
I have been volunteering at the Venice Family Clinic for more
than 25 years and at the Los Angeles Free Clinic for more than
15 years. For more than 20 years, I have taken medical students
from the University of California at Los Angeles (UCLA) and the
University of Southern California (USC) to join me in my volunteer
activities at both clinics. For the past 15 years, the Kaiser
Permanente Los Angeles (KPLA) Family Practice Residency Program
has also provided volunteer medical services to Venice Family
Clinic and the Los Angeles Free Clinic on a weekly basis. As the
Family Practice Residency Program Director, I provide on-site
supervision for these services. I thereby hope to serve as a role
model who embodies the spirit of volunteer community service that
work in a Free Clinic represents. Typically, I take one senior
resident, one or two interns, and a half dozen medical students
from UCLA and USC on my volunteer activities. The KPLA Internal
Medicine and Obstetrics-Gynecology Residency Programs have also
been sending residents to work at the Los Angeles Free Clinic
for the past five years.
Daniel Keatinge, Director of Continuing Medical Education for
the KPLA Internal Medicine Department, currently serves with me
on the Venice Family Clinic Board of Directors. Several years
ago, an advertisement for Venice Family Clinic that gained nationwide
circulation was titled "Why Doctor Hara is a Lousy Golfer."
And last year, I was invited to describe my community service
activities to a group of graduate medical education leaders in
the KP California Division who were attending the annual Marconi
Conference (sponsored by The Permanente Medical Group-Northern
California).
Special Benefits for Medical Residents
In addition to providing much-needed resources to the clinics
they assist, residents find their participation in this program
beneficial for their own personal and professional development.
Residents see cases they might otherwise not see at our KP facilities.
More important, many residents often acquire a sense of social
responsibility that they carry throughout their careers and that
motivates them to maintain similar relationships with the communities
they serve. Michael Wada, a recent graduate of the KPLA Family
Practice Residency Program, has continued his volunteer activities
at Venice Family Clinic and has now enrolled in a fellowship at
UCLA to further study unmet health care needs in Central and Southern
California. Another graduate, Kendra Gorlitzky, serves as full-time
staff physician at the Oscar Romero Clinic, a facility which serves
the immigrant Central American population.
Last year, I was appointed to the California Health Manpower
Policy Commission of the Office of Statewide Health Planning.
The charge of our Commission is to provide funding to family practice
residencies as well as to nurse practitioner and physician assistant
training programs. The Commission is also charged with using State
of California census tracts to identify geographic areas where
health care professionals are in short supply and where the population
has a substantial unmet need for health care. State and federal
funding for health care facilities will both be based on the Commission's
findings.
Conclusion
By actively participating in graduate medical education that produces
practicing physicians for the community--and even more important,
by involving residents in actual volunteer community service and
caring for a medically underserved population--the SCPMG residency
programs in Los Angeles provide a direct community benefit in
the truest sense of the term. This benefit is one that greatly
enhances the value of the KP Program for individual patients and
health care practitioners as well as for society in general.
