Kaiser Permanente's Public Image: Impact & Response | to pdf >>
A Roundtable Discussion

Introduction
For the Kaiser Permanente (KP) community, probably nothing is as frustrating as reading or hearing the media lambaste us over and over again. Television shows, movies, newspapers, legislators, all take their turn beating up on managed health care. This can be demoralizing.

The panel of experts participating in this roundtable discussion address the impact, but more important, they suggest how KP can respond to these constant attacks. I think you all will enjoy the discussion. Join in the dialogue--let us hear from you.
--Lee D. Jacobs, MD, Associate Editor

Don Parsons, MD: First, I think we must realize that KP is a huge target and that we live in a "fishbowl": we are located in some of the most important media markets in the country, Washington, DC, in particular. What would be local news in many other places becomes national news in Washington. This living-in-a-fishbowl phenomenon is not new to us, but recently we have been selected as the favorite target for many of the adverse reports on managed care. When our doctors see KP being trashed in the media, this creates a significant morale problem.

Ann Cahill: I agree, and it's more than a collective demoralization. I think individual physicians take this personally as well. It bothers them when KP receives negative press, because they believe they work for a good company and that they do a good job. They know that these things don't get covered.

Jon Stewart: I think it also may be particularly difficult for physicians because they continue to be held in really high esteem by the public. I was just looking at an opinion poll that showed the positive ratings of different groups: Nurses are up very high, as are physicians, well above the 50% rank, whereas HMOs and managed care plans are down in the 23% level. Unfortunately, I think that because of our structure, Permanente physicians get linked with the HMOs.

Dr. Rasgon: This sounds to me like the phenomenon with Congress: everyone hates Congress, but all love their Congressman. Would you say everyone hates their HMO but loves their doctor? Is that something we need to exploit?

Jon Stewart: Another way of putting it is that everybody hates HMOs, but they think their own HMO is pretty good.

Darrcy Loveland: The impact of negative media is cumulative, and the results can be pervasive. It influences employees' opinions, which affects employees' morale, which ultimately may influence their job performance. Adverse media influences public opinion, which affects KP's marketing and the growth of our Program. Adverse media also influences our members' opinions, which can diminish the level of trust between Permanente physicians and their patients. Finally, adverse media influences legislators' and regulators' opinions. This may lead to increased legislation and regulation to address the perceived harms caused by managed care, which may result in increased costs for the organization.

Susanne Coffey: People like to be affiliated with a winner and a leader, and to the degree which KP can be viewed as a leader in our external environment, we will all be better for it. When bad press prevents that from happening, it naturally affects individuals, and, as Darrcy said, it definitely affects job performance and the ability to stay "on the mark" at work every day. It is particularly difficult when it happens to people who are caregivers.

Dr. Parsons: Another real problem is that reporters fail to understand the distinction between physician-driven, self-managed group-practice forms of integrated health care and other forms of managed care. We consistently get locked in with the worst just because of the ignorance of reporters and others who interpret this phenomenon.

Darrcy Loveland: I agree, Don. Much of the negative press has focused on the managed care industry in general--not specifically on KP. However, negative media about managed care, whether specific to KP or not, often has a negative impact on us. Further, legislation passed to address a perceived harm caused by HMOs other than KP could ironically have a greater negative effect on us than on our competitors. For example, point-of-service legislation introduced to address the problem of a lack of choice of providers would have a greater negative effect on KP, which has an integrated network plan, than it would on those health plans that pay various independent contract providers.

Dr. Rasgon: I want to throw in another observation that goes along with what Don and Darrcy have said about the lack of public understanding of the different kinds of managed care. I recently saw that a joint KP/Harvard survey of the public's knowledge of the term 'managed care' found that between 1993 and 1997, the number of people who claimed to know what the term means had increased from 31% to 45%. That still leaves 55% who have no idea. Therefore, managed care generally remains a great mystery to the public. I'd like to hear others address the question of how one positions oneself with regard to managed care. Do you ignore it or run from it?

Darrcy Loveland: From a government relations standpoint, we have stood with the managed care industry when we have activities and interests in common and when it is appropriate to promote the advantageous features of managed care that are common to all managed care plans. However, as a nonprofit, integrated health care delivery system, we are significantly different from our industry competitors and as a result do not always have the same viewpoints and positions.

Last year, KP distinguished itself from its competitors by joining with two consumer groups (the American Association of Retired Persons and Families USA) and two other HMOs (Group Health Cooperative of Puget Sound and HIP Health Insurance Plans) to support consumer protection standards in 18 areas. These standards were useful in our discussions with the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. As an ongoing government relations strategy, we will continue, when appropriate, to distinguish ourselves from our competitors.

Jon Stewart: I think that we need to differentiate ourselves by redefining managed care for ourselves-- not necessarily for the industry, but for KP. Maybe that means getting away from the term entirely. There is a big debate as to whether you should run against managed care or run with it, or how you should position yourself with regard to the managed care industry. I would prefer to avoid the managed care industry and define ourselves broadly in terms of Permanente Medicine or the KP Promise, emphasizing those aspects of KP that we know matter a great deal to the public, such as physician-directed care and evidence-based medicine.

Dr. Parsons: We are very different from most other members of our trade organizations. The physicians who are treating our patients make the ultimate decision about medical necessity. That doesn't happen in most other health plans, where all medical decisions are subject to health plan review. Also, we exist in an organizational environment that gives us the tools to support that decision-making process and to make the right decisions for the right patients in the right setting at the right time. We have created a unique learning culture in quality improvement.

Ann Cahill: Even when we do things in a way similar to other organizations, we are still different. A striking example is the networks that have been set up in several regions: a Permanente physician manages the network and interfaces with network physicians. This doesn't happen in other plans.

Dr. Parsons: We can emphasize these differences when we are able to communicate one-on-one or to audiences in both the purchasing and public policy communities. We can communicate the wonderful things that we as a Program are doing with respect to innovation in disease-state management, demonstration of quality and efficiency, and the research that is unique in the world of managed care. We have the largest private health services research establishment in the country. When we talk about these things, people express surprise and feel better about KP. Within our own Program, many people are similarly unaware of some of the wonderful things that we are doing that distinguish us from our competitors. With The Permanente Journal, we now have a way to help all people understand the dimensions of the Program.

Dr. Rasgon: Don, you just took the words out of my mouth. Let's shift the discussion from the impact of the negative press and now address some possible solutions for our readers. How do you think The Permanente Journal might help individual physicians deal with some of these issues?

Ann Cahill: The Permanente Journal is one of the best ways to spread information about current research and best practices within our organization. It is also a great marketing tool: This is what we at KP do to advance medicine. It is a great tool to use with the media to combat the negative press.

Susanne Coffey: The Permanente Journal is a testament to the outstanding medicine provided by the Permanente Medical Groups. The Permanente Journal, as well as the recent video created by the Federation, recognizes the Permanente physician and subsequently improves morale.

Beverly Thomas: I also believe that The Permanente Journal is one of the tools that illustrates the KP difference. By sharing the research and other exciting things going on, the broader community can see the unique advantages we offer over our competitors.

Dr. Rasgon: In this era of HMO bashing, and with our new brand strategy in which we look at ourselves as a health care organization rather than a business, do you think The Permanente Journal will help individual physicians to understand this distinction?

Dr. Parsons: I think the simple answer is 'yes.' A nice thing about The Permanente Journal is that it shows the uniqueness of this Program. No other medical group in the United States can possibly publish this kind of journal. The brand strategy will support our reputation further and will allow us to differentiate ourselves from other managed care organizations. The payoff in the marketplace, in the media, and in legislative bodies will be terrific.

Ann Cahill: I also think the Kaiser Permanente brand strategy fits in well. There are many opportunities to bring the tagline 'In the Hands of Doctors' to life. We can have our physicians speaking--whether through media interviews, journal articles, or speaking engagements--about their research, the innovative approach they take in caring for their patients, and their unique ways of practicing. We have many opportunities to advance the KP distinction.

Dr. Rasgon: One of the strategies that I'm hearing for dealing with adverse public opinion is that we are able to personalize care that is physician-driven and can offer evidence-based medicine with quality management, which gives us an advantage over our fee-for-service competitors and for-profit HMOs. I think that is something our physicians can promote. Any suggestions on how Permanente physicians can help get the message out?

Dr. Parsons: It is critical that once we have defined for ourselves what we do, how we do it, and what makes us different, Permanente physicians themselves have a responsibility to get involved with the communities that surround them. Traditionally, outside influences have driven us to become a very introspective organization. Historically, we were rejected by organized medicine and by others who considered our form of practice to be unethical, and we worked for decades to demonstrate over and over again our superiority. Now it is time for us individually, as Permanente physicians, to take the Permanente message into our communities, to our professional organizations, and to legislative bodies. It is only by our taking action that we will regain control over how others think about us.

Darrcy Loveland: Following up on Don's comments, one way Permanente physicians, other providers, employees, and members can get the word out is by participating in 'Voices for Health,' KP's grassroots government relations program. 'Voices for Health' is composed of two parts: the first is a 'Key Contact Program' that links selected KP physicians, providers, and Health Plan leaders to targeted federal and California state legislators. The second part is the 'Action Network,' available to all physicians, providers, employees, and others who are connected to and supportive of KP who want to assist in our legislative efforts. 'Action Network' participants will be asked to do various things such as write letters, call legislators, or participate in "town hall" meetings. As part of our grassroots effort in California, we have invited California legislators to tour KP's medical facilities. Legislators have a greater understanding of KP after having an opportunity to personally view our unique method of delivering health care. I encourage readers to sign up to join 'Voices for Health.' [See sign-up form, end of article.]

Dr. Rasgon: Developing this positive understanding of how different we are--and then getting the word out--is essential. This issue of The Permanente Journal includes a 1953 editorial from The New England Journal of Medicine and a follow-up article from California Medicine about KP inferring that some people felt we were communist.

Dr. Parsons: We have progressed from being seen as communists to being seen as capitalists. I think we are now regarded by some as no better than our for-profit competitors. How else can our physicians and other members of the KP family get involved in the community outside of our Medical Care Program to communicate who we are, what our values are, and how we actualize those values?

Ann Cahill: One way is for our physicians to be active in organizations in their communities. For instance, some of our physicians are active in the medical societies in Maryland, DC, and Virginia as well as in national societies. We can distinguish ourselves through contributing to the community, whether by volunteering at a clinic or by speaking at different places--advancing Permanente Medicine whenever possible.

Dr. Parsons: Health care remains a local community entity, and that is where we make our greatest impressions. Our doctors should speak publicly about the principles of Permanente Practice and about the myths and realities of managed care. We should support these physicians with training and compensation for their efforts. That kind of involvement in community organizations has tremendous payoff.

Jon Stewart: I have advocated the idea that maybe each Medical Group ought to dedicate a couple of FTEs to do exactly the kind of community work that Ann mentioned.

Darrcy Loveland: Our size is our strength. Our large numbers of members, physicians, providers, and employees offer a tremendous advantage. In the grassroots forums I have held throughout the Program, I have discovered that many KP staff are already involved in professional, national, and community organizations based on their various personal interests. However, they may not be involved as representatives of KP or their connections with KP may not be apparent. If KP creates a support system that encourages and facilitates this type of involvement, it would be a plus for our employees, physicians, and providers--and a great plus for KP."

Beverly Thomas: I am also a big advocate of community involvement and think there are a lot of advantages to getting our physicians to increase their visibility. You can think about this another way: When our members come to our facilities for health care, that's also the "community" coming into KP. If we make sure those members leave very pleased with our services, they will carry positive, credible messages about us back to their family, friends, and neighbors. Given our size, I think that is one of our greatest advantages in terms of our ability to have our positive story told.

Susanne Coffey: I think Beverly made some excellent points. We also need to build trust and relationships with key national advocacy groups and with our own members through KP On-Line. We're working now to establish contacts with key stakeholders so that we can have an ongoing dialogue and be able to have a call to action when we need them to speak on behalf of their health care organization or attend a meeting.

Dr. Rasgon: We have been talking about how to increase physician and member involvement, and Susanne mentioned KP On-Line. How does everybody see new technologies--that is, computers and the Internet--changing the way we can present our image?

Susanne Coffey: Electronic communications is essential. Influential people--national or community opinion leaders and politicians--get information from the Internet. While developing the breast cancer guidelines, we found that when a national breast cancer advocacy group formed with a negative perception of KP, its message was electronically distrib
uted across the country. We have to be online and be able to use that technology at a moment's notice.

Ann Cahill: I agree. I think it is critical that we use the technology that is available, and physicians who are technologically adept have opportunities to contribute in this area. This consideration relates to the previous issue about burdening physicians who feel overwhelmed. We must appeal to the things that already interest them. If we have physicians who are interested in politics, we should encourage them to be a part of our lobbying efforts. Physicians interested in technology can be invited to assist us with our website. We may have physicians who don't like any of that but are very involved in their places of worship--they could speak regularly on health topics. We must help our physicians find opportunities that match their interests so they can help expand people's knowledge of KP.

Darrcy Loveland: I hope to use our new technologies--especially e-mail and the Internet, to communicate more quickly with members of 'Voices for Health.' These technologies will enable us to quickly issue action alerts when we need immediate communications with legislators.

Dr. Parsons: We tend to think of new technology as being impersonal and sterile. People need immediate response and attention to their concerns, and our website offers an opportunity for knowledgeable physicians and nurses to participate in chatrooms and to send e-mail responses to members' questions. Doing this can become an expression of our compassion, our interest in our members, and our desire to help them with their problems in a rapid fashion. I think this technology has the potential for actually enhancing our ability to touch our members.

Susanne Coffey: What's so wonderful about the electronic media and the Internet is that they transcend geography and time. They provide 'just-in-time' information, whether it is clinical information, a national issue, newsletter, or press release. The Internet is like an old-fashioned bulletin board: Everyone has access to it, and we can all share information.

Dr. Parsons: It allows not only the dissemination of information, but inquiry and response. Sometimes we assume that when we give information to people, we have met all their needs. The Internet offers us vast opportunities for conversation internally with our own physicians and other health care providers. Darrcy made a valid point about the usefulness of having members of the legislature and other officials come to our facilities, where they get a visual impression as well as a handclasp and conversation with our people. This connection can be made in the world of virtual reality as well. We can have people come to our Internet facilities and get much the same experience. As time goes on, technology will evolve to allow us to present multimedia demonstrations and interactive conversations.

Dr. Rasgon: Let me ask a question, leaving the high-tech and going to the low-tech. It seems to me that people of influence, such as legislators, read Letters to the Editor. As an organization or as individuals, we don't seem to use letters for presenting rebuttals or for refuting the "bashing" that goes on. Would anyone like to comment?

Jon Stewart: I don't know whether we do use letters for this or not, but we should. As a former newspaper editorial writer myself for many years, I was always chagrined to look at reader response surveys and see how the Letters to the Editor column was always three times more popular than the editorial column. The Letters section is one of the most read pieces of the newspaper, and we should take full advantage of that. For instance, when local controversies arise that are appropriate for a Letter to the Editor, we could easily distribute to our Medical Groups some "talking points" that they can adopt themselves by putting in their own words and adding their own arguments.

Darrcy Loveland: I agree with Jon. Every Letter to the Editor is an opportunity for us to tell our story and to distinguish ourselves from the rest of the industry. We should be out there doing this more.

Beverly Thomas: You probably don't see as much letter writing specifically about managed care. We have not done a lot of rebuttals, because our dilemma is whether or not any "bashing" has been directed at KP in Atlanta; because it has been directed toward HMOs in general, do we want to own the problems of the industry and have people identify these problems with KP instead of having everyone share these problems across the board and have the HMO association issue whatever response it finds warranted?

Dr. Rasgon: I know that some people write Letters to the Editor but can never get them pub
lished in the newspaper. Is there any way you are more likely to get them published?

Beverly Thomas: I think your most credible Letters to the Editor come from members. We had a member who wrote in about great care her husband got when he was having chest pains. It really packed a punch because it came from a member, who is perceived as being a more objective source than we are.

Dr. Rasgon: Here is a common scenario that I encounter as a physician: Something about patient care will come out in the newspapers or be on 'Night Line,' '20/20,' or '60 Minutes' and will often be erroneous or exaggerated. Patients see these TV shows and come in with several questions, even if it was something that happened on the other side of the country. This scenario puts the Permanente physician in a difficult position. What assistance can we give physicians to help them deal with these all-too-frequent situations?

Ann Cahill: In the Mid-Atlantic Region, we distribute talking points as quickly as possible so that physicians and staff have the information they need when asked. We do need to give our colleagues across the country a "heads-up" when something happens, because it may get reported nationally. We should share our talking points so that we can be consistent in our messages throughout the Program.

Dr. Parsons: We've recently gone through several months of debate about coverage of Viagra, for example, where different parts of our Program may have had different policies, leading to confusion. People saw national articles that reflected a KP position that perhaps was different from what they encountered in their own jurisdiction. Communication by e-mail or other electronic means would have facilitated understanding. Hooking everyone into the same system should be an objective of the Program over the next year.

Jon Stewart: I think an even higher-order objective is to get a universal Intranet up and running. That was supposed to happen earlier this year. For various reasons, partly financial, it has been delayed. This is a case where a relatively small amount of money can have an enormous payoff in our ability to communicate with one another.

Dr. Rasgon: Do you see this as a competitive advantage for us because our physicians work only with KP, whereas other HMO physicians work for several other managed care organizations?

Dr. Parsons: It is not only a competitive advantage, but it is an opportunity for building commitment and for improving morale. Information is what we are all about, Scott. For example, with the Care Management Institute, we now have an organization that can extract the very best in this Program, package it, and disseminate it quickly to other parts of the Program. That can't happen in any other national medical care system.

Jon Stewart: It has been suggested that maybe we need a sort of nonclinical version of CMI to identify, collect, and disseminate nonclinical Best Practices throughout the organization. I suspect that the mere existence of a good Intranet will do some of that all by itself.

Dr. Rasgon: We have discussed ways to get information out to the public, but also among ourselves. I get the impression that you believe The Permanente Journal as well as the Intranet are avenues for doing this. I also get the impression that you believe the brand strategy is a way to differentiate ourselves. As we conclude this dialogue, do you have any further comments for our readers?

Jon Stewart: As I said in the beginning, we need to say managed care--or at least what people think of as managed care--is in the past. Now we are coming into what it really means to manage care for better outcomes. This is what Permanente Medicine is about. It is about evidence-based medicine, physician-directed medicine, and high-quality care and service-–all the things that KP promises to be about. We must define managed care in those terms, because those are the terms that will continue to distinguish us from other managed care organizations.

Dr. Parsons: I would like to think that we could be the 'pebble falling into the pond': learning to communicate more effectively in our own Program enhances our ability to affect public policy and what is going on around us--in widening circles as it were--and so creates the opportunity to affect the way systems of medical care are developed for all Americans. Our ability to communicate about these issues will give us enormous influence that will extend beyond our own boundaries.

Jon Stewart: Yes, we have this great opportunity to define the future for ourselves, but that job must be done by physicians and providers. They really need to step forward and grapple with that responsibility. If they don't do it, somebody else is going to do it for them, and they may not like the way it comes out.

Beverly Thomas: There is a lot of 'HMO bashing' going on, and effective communication will be critical for us as an organization. I am concerned that when people hear the same negative things over and over again, some people in our organization may begin to second-guess themselves or some may even start to believe and accept the negative. One of the things we have to do internally is to remind ourselves how great we are, what positive things we are doing, and the impact we are having. We must believe in ourselves first and then share that belief with others.

Ann Cahill: That's true, Beverly. Sometimes we beat ourselves up so much that we forget how good we are! Every day Permanente physicians raise the quality bar for medicine. Our future is to continue to be that bar-raiser. The Permanente Journal helps us to share–-internally and externally–-the innovation evident in Permanente Medicine, which improves health care overall in America.

Darrcy Loveland: Continuing what Jon said, if we want to differentiate ourselves, we all must be out there telling our story. That should be viewed as part of all of our jobs. As an organization, we must encourage our physicians, other providers, and employees to become more externally focused. We have a good story to tell, and if we do not tell our story, as Jon said, then someone else will. Once again, I encourage those who are interested in helping us share our story with legislators to sign up to join our grassroots government relations program, 'Voices for Health.' [See sign-up form (PDF document, 77k)]

Susanne Coffey: From a Programwide perspective, we will continue to position KP as a leader and to collaborate with organizations that lead national policy and opinion. The key for us is that we must continue to provide strategic communications to multiple stakeholders.

Dr. Rasgon: I would like to thank our panel participants for taking the time to join us for this discussion. I believe that you have raised some excellent ideas that will help our physicians deal with the HMO-bashing that permeates our society so that they can better relate to their patients and deal with politicians and the public at large and can continue to make KP the leading health care organization in the country."