Permanente Medicine:
The Permanente Medicine Roundtable: Defining our Practice Principles

The following conversations have been edited from a day-long Permanente Journal roundtable discussion on Permanente Medicine held in Denver in late 1998. Participants included Lee Jacobs, MD, Associate Medical Director, TSPMG; Genie Komives, MD, then-Acting Director of the North Carolina PMG; Don Parsons, MD, Associate Executive Director of the Federation; Les Zendle, MD, Associate Medical Director, SCPMG; Al Mariani, MD, Chief of Surgical Services, HPMG; David Shearn, MD, Director of Physician Education and Development, TPMG; Jed Weissberg, MD, Associate Executive Director of the Federation; Andy Wiesenthal, MD, Associate Medical Director, CPMG; Walid Sidani, MD, Associate Medical Director, OPMG; Marty Lustick, MD, Associate Medical Director, MAPMG; Paul Wallace, MD, Director of the Clinical Practice Guidelines Program in the Northwest; and Federation staff members Leslie Francis, Sally Stephens, and Jon Stewart.

Why Define Permanente Medicine?
Les Zendle: This work is not only a good opportunity to do some external communication about who and what we are, but it's also a way of dealing with some of the morale or ethical issues Permanente physicians are facing. There is so much media and public discussion about "managed care," and it focuses on anecdotal "horror" stories, which are not representative of the quality of care provided by Permanente physicians. More clearly defining Permanente Medicine could counter some of that, both internally and externally.

Al Mariani: There are horrible free-market abuses going on in health care, especially by our for-profit competitors. It is essential to the survival of Kaiser Permanente that we find a way to differentiate ourselves from them. Not only from the for-profits but also from the staff models where the physicians work for the health plan. In our group model, we work with the health plan. We need to promote the value of the independent, prepaid medical group model in the national consciousness. It represents some essential qualities that few people outside of the organization--and a lot of people inside of it--don't appreciate.

Walid Sidani: A definition of Permanente Medicine is sorely needed. It should permeate several activities and could enhance our ability to communicate, in a common language, our values and principles. We should use it in our recruitment and orientation efforts so that candidates and new physicians know what is expected of them.

Marty Lustick: I think one of the critical pieces of this work is to answer the question: What is it about Permanente Medicine that distinguishes us from the rest of the world and allows us to work out some of the tensions and the ethical dilemmas that confront physicians in the era of managed care? If we can clearly demonstrate and communicate that our solutions to these dilemmas are the most meaningful ones for this society, that's going to be a critical message.

Lee Jacobs: I think we need to be clear that we're not creating anything new. We're just defining what's been there all along--what makes us unique. I would also emphasize that the language we use is critical. We all use terms differently, and we may mean the same thing or we may not. It would be helpful if we could end up dealing with the language so that we could all use the same terms and know what we mean when we talk about Permanente Medicine. Language is very powerful.

Genie Komives: I agree about the language. But the discussion documents we're dealing with--the work that's already gone on in this project--do include some new ideas. For instance, this work gets into setting some really concrete metrics to decide whether or not we're living up to what we've defined. I see the potential for a sense of threat in there--like, if you don't measure up, you're no longer a Permanente Medical Group. I don't know if that's necessarily what we want to convey.

Lee Jacobs: I think we need to present Permanente Medicine in such positive and meaningful terms that everybody in the Program will want to be on board. No one would say, "That's not me." That's how we overcome the potential for this to sound like a threat.

Jed Weissberg: Good point. But maybe there's a dark side to this. What if you don't make the grade? Or what if there are issues of divestiture, as there have been in parts of the Program? And what would constitute Permanente Practice even outside a relationship with a Kaiser Foundation Health Plan? These issues get to another question, which is: Should this definition describe our current state or our future, aspirational state? That's especially relevant when we talk about what constitutes "quality medicine," which is one of our performance principles.

Genie Komives: To the extent that we've not necessarily done a good job of communicating what we are, there's an aspirational and demonstrational quality to this work. But that doesn't necessarily mean aspiring to be different than we are. We often feel like we're there in terms of quality goals, but we just can't prove it.

Marty Lustick: I think in some ways it is also a value statement, which hopefully describes who we are, what we aspire to be, and the standard we hold for ourselves. Defining Permanente Medicine is part of what we are. It's actually having a set of standards that we hold everybody to and committing to the environment of the learning organization.

Does Permanente Medicine Depend on Kaiser Permanente?
Jed Weissberg: When Jay Crosson (Executive Director of The Permanente Federation) started talking about the basic structural principles of Permanente Medicine, or Permanente Practice, he was talking about it in the context of a not-for-profit health plan. The issue is being revisited in this effort to better understand what it is about Permanente Medicine that makes it unique. Because, with some groups looking at possible divestiture, it may be necessary to explore whether you can practice Permanente Medicine in a different context.

Les Zendle: The issue of practicing Permanente Medicine outside the context of a not-for-profit health plan is not the discussion that worries me. I have to say that I don't particularly want to practice Permanente Medicine without this particular not-for-profit health plan--Kaiser. To me, they have to be practiced together.

Jed Weissberg: But some Medical Group leaders nonetheless feel the need to have at least the intellectual experience of thinking this through. This is a brave new world, and we have to give ourselves some intellectual space to explore these concepts.

Lee Jacobs: It may be that Permanente and Kaiser are so intertwined in our definition that it's not Permanente Medicine without Kaiser. I'm not sure that's the case, but I'm saying we need to have that discussion. Basically, I agree with Les that I wouldn't know how to practice Permanente Medicine without the business competencies that Kaiser brings to the definition. I don't think we could do it without them.

Marty Lustick: I think that focusing on what Permanente Medicine means in the absence of Kaiser actually serves two positive roles. One is that it helps us understand where the gaps are in our performance and what we need to do to improve, no matter what happens in the larger partnership. But also, it ultimately makes it less likely that we'll have to deal with that possibility; whereas if we don't plan for it, the likelihood of it actually happening may increase. If the partnership is going to thrive in the long run, we have to look at standing on our own two feet. To the extent that we're successful at driving our own performance as a medical group, it becomes less likely that we'll have to go outside the partnership.

Paul Wallace: We have to be careful about what we mean by "Kaiser." There's Kaiser the corporation, but there's also a set of values that are implied by that name. Look at the relationship with Group Health. There have been tensions around the affiliation, certainly, but there's a very close parallel with our values and theirs. I think it remains conceivable that a Permanente Medical Group could have a very similar relationship with a different organization so long as it had similar values.

On the Key Principles of Permanente Medicine
Lee Jacobs: I would say there are three principles that are key. Number one is physician leadership, which should be a stand-alone bullet, top of the list. That's distinguishing. Self-governance is just an aspect of that, not a separate principle. The second one is the idea that we are the best advocate for patients--however you wordsmith it. And the third thing is the group ethic. It's essential to what we are.

Marty Lustick: I think that more than anything our group ethic distinguishes us from the rest of the world as a kind of protection against making the wrong responses to these ethical issues we all face. Because we're part of a large group, we have to struggle and come up with meaningful answers to these questions. We actually do hold each other to a standard, whatever that standard is. For instance, we struggle over any little innovation in our compensation system, asking how it might affect physicians' decision-making. Private practices don't protect themselves that way.

Al Mariani: Just to carry the argument about physician leadership a little further, I agree that the culture of physician leadership needs to be at the top. The regions that have been the most stable over time are the ones that were steeped in that culture. Leadership really is the center. And this isn't fuzzy rhetoric. I'm talking about coming up with $100,000 or whatever to run a peer-to-peer survey or a quality-of-service survey, or all the other measures that we do on the really basic things. By measuring them, you send a message to the frontline that this is what the leadership expects; this is what we'll measure. And then, a real leader has to have the courage to do something about the outcomes. That needs to be our culture--defining the essential things, measuring them, and then acting on the outcomes. Our medical group structure gives us the ability to do that.

Marty Lustick: Another thing that distinguishes us is our ability and commitment to be a learning organization, which is how we are able to achieve all those performance-related principles, like great medicine. Because of the way we're organized--as a large group practice with an information system infrastructure--we have a unique opportunity to be a learning organization in ways that others don't.

Don Parsons: We've talked a lot about the importance of the physician-patient relationship and being an advocate for the patient; and yet, we've been designing adult primary care models based on collaborative care teams where physicians may not in fact have a lot of contact with many of their patients.

Lee Jacobs: I don't think that's incompatible with the patient-physician relationship principle. There has not been much discussion here about collaboration in multispecialty care teams, which is clearly a part of Permanente Medicine. And I don't think that team-based care is at all at odds with acting as the best advocate for patients.

Les Zendle: I'm a huge advocate of advance practice providers on care teams. But in many systems they are used as access "barriers" to doctors. They sometimes aren't being utilized to bring their distinctive competencies to Permanente Medicine. I'm hoping that the primary care models that are being developed augment the relationship between the patient and the physician rather than create a barrier.

Putting the Principles of Permanente Medicine into Practice
Walid Sidani: As we agree on the principles, how do we assure that they are practiced? Our principles may challenge exactly what's happening today, such as team-based care. If what's happening today really is against a principle, then our activities need to change. Most of the time, we expend a great deal of energy developing principles; yet, we don't spend any time really challenging what we are actually doing against the principles. If we state that the physician-patient relationship is a principle, then we need to assure we've defined what that means throughout our medical groups and to our members.

Genie Komives: That's right. As part of the measures and the monitors, we must ask members several questions. Do you feel as though you have a relationship with your primary care physician? Do you feel as though your care is well coordinated? Do you feel there are any barriers to seeking the care that you need, when you need it?

David Shearn: Genie's point raises an issue about the proposed principles that concerns me. They don't explicitly reflect a bias toward the patient's needs or the patient's preferences or the patient's view. We are discussing what we'd like the principles to say based on our own views, needs and preferences, but the patient's voice isn't here. It might be interesting to actually bring patients into a forum like this and discuss it.

Lee Jacobs: I'd be cautious about that. We're trying to define and articulate who we are. And in fact, what we are may not be the appropriate choice for all patients. We're not trying to model this so it's attractive to patients. I don't think that's what the goal is.

David Shearn: But patients are increasingly redefining the patient-physician relationship. Increasingly, people are using the Internet and coming into our offices having completed a literature search. As a result, they are telling us what treatment they want. Those patients are redefining what it means to be a partner. I think we can respond to this dynamic more effectively than other systems, because, as a group, we can adapt to things like this by coming up with systematic approaches involving the Internet.

Paul Wallace: Yes, that's part of what's been lost in these proposed principles by leaving out customized, coordinated care as a stand-alone principle. The customized part implies a relationship with somebody.

Les Zendle: This fits right into the discussion around alternative or complementary medicine. It's true that in some places patients are demanding alternative medicine. But is alternative medicine or whatever else the patient demands necessarily part of Permanente Medicine? It's a struggle. We have physicians who feel it's appropriate to provide these alternative therapies, while others feel that if we do this, we might as well sell snake oil.

Genie Komives: But we have already defined some principles here that will help us answer these questions by giving us something to evaluate them against. For instance, evidence-based practice is called out as an aspect of the quality principle. Offering alternative medicine may be a patient satisfier, which will improve the patient-physician relationship. But it may not meet the evidence-based medicine criteria. If we line up issues like these against our principles and they don't meet the criteria, then we can effectively explain why they are not part of Permanente Medicine.

Marty Lustick: But these principles we keep discussing, such as the strong patient-physician relationship and quality medicine, these are things that everyone in health care is striving to provide. It's just so generic that it sounds empty. What is it about the way we're trying to practice that distinguishes us from the rest of the world? What makes us Permanente physicians?

Walid Sidani: The challenge we have is to inflect meaning into what we define as our principles. How does this translate into the medicine we practice every day? I think some of our discomfort is based on the gap we are experiencing between our principles and our practices.

Marty Lustick: What do these principles really mean? For example, when we talk about the patient-physician relationship, I can only conclude that we'll never achieve the level of bonding between our physicians and our patients that existed in my father's practice. He visited patients in their homes, and patients received their care only from him. What is our concept of the patient-physician relationship? What does it mean to the marketplace? What do we bring that's unique? It certainly is not the kind of high-touch, individual, emotional bond that others can provide.

Andy Wiesenthal: We need to articulate our unique relationship between a team of professionals and the patient. Let's say I'm caring for somebody who has coronary artery disease. Perhaps a care management nurse and pharmacist are helping me manage the patient clinically. In addition, a nutritionist helps the team manage the patient's diet.

As the physician, I am seen as the lead on this team. However, I'm not Marty's father; I'm not a lone eagle. I work with a number of other professionals who all contribute through me and with me to take good care of people. And the patient maintains a relationship with all members of our team.

Walid Sidani: Exactly--the bottom line is how the patient experiences that team.

Jed Weissberg: So maybe we should be talking about the Permanente-patient experience, which encompasses the broader relationship between patients and the medical group, which ideally acts as a kind of extended care team.

Living Up to the Quality Principle of Evidence-Based Medicine
Jed Weissberg: With all this in mind, can we justify that we're practicing evidence-based medicine, as our quality principle would demand? And what are we doing about that?

Don Parsons: Evidence-based medicine must be central to what we do. We aspire to practice it, and we create guidelines around it. But do we actually practice it? If we are going to claim that we live by our principles, we'd better be sure that we're either living up to it or that we couch the principles in terms of aspirational goals as opposed to reality. I would think that we could be challenged on any one of these points.

Paul Wallace: I guess I'd take a step back and say, look at evidence-based medicine as a tool for achieving quality improvement. So the bigger question is: Are we using the tools of quality improvement that include evidence-based medicine? We have to phrase the question right. Are we really committed to improving our practice using the relevant tools? And I'd say the answer to that is clearly yes. For instance, measuring the variation of rates, say in mastectomies, is a commitment to quality improvement, because we haven't ignored it. Subsequently, we must commit to ask what the appropriate rate is. I would say that is totally consistent with practicing evidence-based medicine with sort of a colloquial definition.

Les Zendle: Evidence-based medicine means so many different things to different people. To some people, it means that you don't do something unless you have double-blind randomized control studies that prove that something works. Of course, if we only did things when we had double-blind randomized control studies, we wouldn't do a whole lot. It's also used as a reason to withhold certain things or to not do things or to cut costs.

I like the fact that we are constantly looking at data about what we're doing and the effect it's having. Our physicians clamor for data. We don't give them enough data. And there's nothing wrong with the cycle of physicians looking at data and then questioning its accuracy, especially since nine times out of ten, the data aren't very accurate. That's all part of learning and improving.

We also have to be careful when we combine the term "evidence-based medicine" with the term "variation." No one should expect that we're going to get rid of all variation in our system or that eliminating variation is even our goal. We need a certain amount of variation.

Networks and Permanente Medicine
Walid Sidani: Where do networks fit in under Permanente Medicine?

Al Mariani: Networks aren't Permanente, but Permanente must plan to manage networks. Permanente to me is a self-governing group of salaried physicians who have an exclusive financial relationship with an autonomous, regional, nonprofit Kaiser Foundation Health Plan. Anything else to me isn't Permanente. Of course, this is just my opinion. However, it is an opinion based upon the long observation that more often than not when these principles are compromised, the organization does not do well. Within the framework of partnership the medical group has the responsibility for guiding the Health Plan to appropriate patient care. This would mean managing the networks for patient service and quality of care for those areas of medicine that cannot be internalized by the Permanente Group.

Marty Lustick: I actually disagree, because they may be part of what we need to look at to assure Permanente's long-term survival. If the population management techniques we're trying to develop are successful, then we'll need to promulgate those techniques into our communities. That's part of contributing to community health. In fact, part of what Permanente Medical Groups can do--and already are doing--is develop infrastructures that manage network physicians, teach them about Permanente Medicine, and support their delivery of Permanente Medicine. I think it's consistent with where our group is going.

Lee Jacobs: We probably have one-third of our physicians in Georgia practicing without any kind of knowledge of Permanente Medicine. But part of Permanente Medicine is managing those relationships and incorporating the care that's delivered into our care delivery plans. It's incredibly restrictive, and in fact, naïve in today's world to think that Permanente Medicine can only be practiced in a totally self-contained model. I don't think there's such a thing anymore.

Al Mariani: I've worked with network doctors for 18 years. While they have uniformly been professionally competent, the relationship was mercenary. Some take advantage of us, and some don't. Their goals are not necessarily aligned with ours--for instance, evidence-based optimal population care. Our careers are tied to the success of our medical group. Theirs are not.

Paul Wallace: I think of it in subsets--the Permanente Medicine we practice within our Medical Groups and the care we delegate, which is really Permanente-affiliated care. But in our increasingly competitive environment, there's the ability to extend more and more of the principles of the Permanente group practice out into the groups that we contract with. Increas
ingly, in our contracting, we're demanding quality measurement and a variety of the accountabilities that we expect from ourselves within the group. To me, the value of Permanente Medicine is to put as much of that into the contract as we can and still get the care we need to deliver to patients.

Marty Lustick: Another way to look at it is to imagine that we were not affiliated with Kaiser. What would we want in order to continue our practice of Permanente Medicine? What would we want our relationships to be with other doctors in the community? Would we potentially bring our expertise in network management to the table?

David Shearn: Luckily, we don't have to resolve what role networks should play in Permanente Medicine today. But one thing I am observing--since I've been involved in these kinds of conversations so many times--is that something's different about our discussion than others I've participated in. We have reached some sort of consensus about our values, and they give us a reference point from which to have this discussion of networks. Not that we've reached a resolution, but knowing more clearly what we stand for changes the conversation, I think, in a better way.

Measuring Permanente Medicine
Jed Weissberg: Now that we've talked about our principles and their application, how would we measure them to exhibit our responsibility and accountability? What are the most important accountabilities that need to be measured? Do our existing measures get to them, or do we need to develop new measures?

Marty Lustick: In some cases here, we're talking about principles that address behavioral issues, like governance, making it much more difficult to define the right metric.

Les Zendle: Another thing, are we saying that once we put out a measure, we'll have to be willing to say that groups will have to meet a certain threshold to be considered Permanente?

Al Mariani: No physician manager can hope to have an accurate sense of how well things are working without measurement. Every day there are tens of thousands of patient interactions. There definitely should be standards for measuring patient service, quality of care, peer-to-peer service, and medical-legal trends at a minimum. It is the responsibility of the Permanente Medical Groups management to measure these and possibly other parameters of good care and then act on deficiencies. One could debate whether standardized measures are required as long as there is measurement and action based upon these measurements.

Andy Wiesenthal: There's a danger that all that gets measured is the existence within a medical group of proper policies and procedures and that in fact there may be no execution. So where's the beef? We have to focus on policies and procedures for compliance assessment. For our purpose, we really ought to try to focus much more on actual outcomes wherever we can. And maybe we don't ask people to meet a threshold initially but rather to provide evidence that the standard is part of their Medical Group's culture and the activities they're engaged in.

Don Parsons: But don't we currently have a limited menu we can use today? We could ask whether the group is MDQR- or JCAHO-accredited? Are they a prepaid group practice? Do physicians make the clinical decisions? Do they have a board of directors? These are some of the criteria that would determine whether a group is Permanente.

Andy Wiesenthal: I would argue that right now, people will push back and make a really cogent argument that there's too much change going on to take on new metrics. And we need to recognize that there are differences between regions of the country and allow some slack for that. At the same time, we can let groups know what the endpoint is and what the expectations are once things stabilize for them.

David Shearn: Menuing is another way of dealing with this. Give Medical Groups 12 measurements,
and ask them to pick, say, six based on their own strategies and local needs. Set a target date for achieving those initial measures, and then ask the group to move on to others.

Marty Lustick: Does MDQR look at elements like our group ethic and similar issues as they conduct their work? Do they evaluate groups against what it means to be Permanente?

Genie Komives: No, they don't. My thought is as we define the Permanente Medicine principles or values, we'd clearly want to include measures that differ from MDQR's. But if we look at the specific measurements within MDQR, are we supposed to come to an agreement or recommendation about establishing a bar and whether that should be regional or national?

Andy Wiesenthal: It sounds clear that we're going to set a national bar. But there are questions about how that's going to play out, over what timeframe, and how aggressive it's going to be. Will we start locally and move toward national standards? If we're going to set a bar, it should be a national bar eventually. It doesn't have to be there tomorrow or even next year. But the goal is to be able to tell patients that they will get the same high-quality care wherever they go. If we can guarantee that, I think we have something to distinguish ourselves, because nobody else can guarantee that.

Les Zendle: We want to identify things that are going to demonstrate our ability to deliver high-quality health care in every Permanente Medical Group. For example, it means that every Medical Group goes through a performance review every year, or MDQR, that the group sets strategic goals that are based not only on what's going on in their community but nationally, as well as on best practices around the Program. When the group falls short of where they want to be, they put resources toward improving in those shortfall areas. This should happen over a reasonable timeframe.

Participants of the Permanente roundtable; from left to right: Les Zendle, MD; Paul Wallace, MD; Lee Jacobs, MD; Marty Lustick, MD; Jed Weissberg, MD; Walid Sidani, MD; Al Mariani, MD; David Shearn, MD; and Andy Wiesenthal, MD.

Don Parsons: There's a widespread perception, at least in the external audiences that I talk to, that if you're not measuring something, you're not managing it. One of the things that I think is important about Permanente Medicine is our ability to demonstrate quality to those employers who are asking for it. We have to take that very seriously. Even though it's attractive to score very high on the obvious HEDIS measures, and let it go at that, it's very important for us as physicians to try to keep that quality spectrum broad.

Walid Sidani: I am hoping that Permanente will set some specific performance targets and specific measures. If we decide that certain outcomes are important, and we agree on the measures for them, there is no reason why they cannot be integrated into MDQR. MDQR can then become the organization that determines or certifies Permanente Medicine.

Paul Wallace: This struggle with measurement is so familiar. There's this dilemma about even figuring out what we want to measure. Then we need to determine whether a metric is associated with it that reflects an outcome or a process. And then there's the targeting and the surrogate if you really can't get at it. And then at some point, you have to loop back around and determine whether it's an important measure. What we probably need to do is just figure how far we can push it and foster an improvement environment. It has to be a long-term strategy with some sort of launch.

Genie Komives: I think looking at ways to ensure that the Medical Group is truly accountable to these principles is important. I think looking at incentives and compensation--the payment structure and how that's implemented--is a valid activity.

Les Zendle: It sounds like we want to measure some areas that we feel are important but are unsure of how to measure them. Then we've got things that we know how to measure, and the reality is we're not sure how important they are. I'm afraid we could focus on areas that we are able to measure and potentially miss those that are really important--the things that are going to allow us to identify real performance problems. That is not the way to get physicians and professionals to improve quality.

Jed Weissberg: I think we've done a really good job of defining a lot of the problems about how to measure Permanente Medicine, even though there are so many dimensions to it. I do not think we have closure on very many questions, but we've had a chance to identify the critical issues. Now we need to continue to take these issues to the frontlines, where the final work of defining Permanente Medicine is going to happen.

The Roundtable transcript was edited by Jon Stewart, TPJ Communications Editor, and Randa Ghnaim, Communications Consultant, Program Offices.

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