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Health Policy Advisory Center No. 55 November 1973 HEALTH / PAC BULLETIN THE KAISER PLAN Editorial: HMO's When Forbes and Fortune magazines run successive articles contending that health maintenance organizations (HMO's) are " sensible surgery for swelling medical costs, " we know that big business is in- terested. When the supermarket magazine Family Circle publishes a story entitled " Is There An HMO In Your Future? " we realize that the official word is spreading to the American people. Yet most Americans don't understand the HMO concept. An HMO is a health care organization which is intended to provide comprehensive services to a vol- untarily enrolled membership at a pre- paid fixed fee. Usually an HMO is affili- ated with one or several hospitals. It may be funded privately, publicly or by a combination of both; it may be for profit - or " profit non -. " Doctors can practice full- time or part time - within the HMO, and can be salaried or paid fee service - for - . Only three years ago there were 30 HMO's. Today there are over 60 with eight million subscribers. At least 46 in- surance companies are participating in or have " exploratory interest " in operating 63 HMO's. Blue Cross hopes to open 280 by the mid 1980's. Big business is also joining the band- wagon: the elite policy forming - organiza- tion, the Committee for Economic Devel- opment representing most American busi- ness leaders and with considerable clout on a variety of government policies, en- dorses HMO's in its April, 1973 report. Westinghouse is studying the possibility of starting one in Florida. Texas Instru- ments is already involved in setting up one, and Litton Industries wants to give " seed money " for a number of HMO's. Connecticut General Life Insurance Com- pany and the Equitable Life Assurance Society have made significant commit- ments to HMO's. Connecticut General's new subsidiary operates them in New York, Arizona and Maryland and Equit- able organized and recruited subscribers for the Lovelace - Bataan HMO in Albu- querque. One of the most successful HMO's is the Kaiser Permanente - medical care pro- gram, a prepaid group practice which has been operating in California for over 30 years. Kaiser's membership in California, Portland, Hawaii, Denver and Cleveland exceeds two and a half million. Other HMO models have emerged that are different from Kaiser. Most notable are the foundations for medical care, cre- ated by private doctors (See BULLETIN, February, 1973). A foundation, unlike Kaiser, is not a visible institution but simply a mechanism through which paper and money flow. Care is provided in pri- vate doctors'offices and hospitals where the doctors have admitting privileges. Pa- tients pay insurance companies, insur- ance companies pay the foundation, and the foundation pays the doctor or hospital CONTENTS 4 Kaiser > on a fee service - for - basis. Prepaid health plans (PHP's), particu- larly growing out of California's Medicaid program, are another HMO innovation. The state pays the PHP a fee for each Medicaid patient enrolled and the PHP provides care at its own clinics or at separate doctors'offices and hospitals through contracts. The main success that HMO's can claim is cost reduction. Kaiser can provide a package of services at lower cost than identical services would cost in " main- stream " medicine. The way in which an HMO reduces cost is by lowering the use of services by its members. Kaiser mem- bers, for example, spend half as many days in the hospital as a similar popula- tion of Blue Cross / Blue Shield subscribers. And the amount of surgery performed by Kaiser compared to fee service - for - practice is distinctly lower. In the case of hospitalization and sur- gery, which most Americans are sub- jected to in dangerous and costly excess, HMO's can perform a positive service. But HMO's will also tend to lower the availability of services that are not pres- ently performed in excess. At Kaiser, am- bulatory care is not easily accessible- large numbers of patients complain of several week waits for appointments, of rushed impersonal treatment, and of be- ing unable to find and keep a personal physician. Thus HMO cost reduction goes hand in hand with a general inaccessibility of services. The reason for this is the work- ings of the profit motive. Whether for- profit or technically " profit non -, " private corporations have always committed themselves to maximizing their income, reducing their expenditures, and using the surplus for expansion. The profit incentive leads private HMO's to limit services by hiring an inadequate number of physi- cians and other personnel so that patients will be discouraged from seeking care. In this way, expenses go down and sur- plus goes up. HMO's, then, take the profit incentive of fee service - for - medicine and turn it on its head. Whereas fee service - for - doctors and hospitals make more money by see- ing more patients, performing more op- erations and hospitalizing people longer, HMO's increase their net income by doing less. Either way the situation can be dele- terious to people's health. Besides the conflict between cost reduc- tion and availability of services, private HMO's oriented primarily toward their surplus income are actually unable to cut costs significantly over the long run. For equivalent services, Kaiser costs less than Blue Cross / Blue Shield, but Kaiser's rate of cost increase is just as great as, or greater, than the national rate of increase. Thus HMO cost reduction is a one shot - af- fair; if the entire health system switched next year from fee service - for - financing to HMO financing, the costs of care might dip down, but would then inflate as rapidly as ever. Within a few years any cost reduc- tion would be virtually cancelled out. Again the reason is profit. Each pro- vider and supplier of service whether - the construction company, the manufacturer of the EKG machine, or the doctor - will raise prices as fast as possible in order to make more money. If HMO's are no long term - answer to cost rises, do they solve the other com- ponents of our health crisis? Here the an- swer is even simpler - they do not. Even Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone (212) 267- 8890. The Health - PAC BULLETIN is published 8 times per year; January, February, March, April, May, Sept- tember, October and November. 3 special reports are issued during the year. Yearly subscriptions: $ 5 stu- dents, $ 7 other individuals, $ 15 institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Oliver Fein, Nancy Jervis, David Kotelchuck, Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake, Thomas Bodenheimer, Judy Carnoy. San Francisco office: 558 Capp Street, San Francisco, Cali- fornia, 94110, Telephone (415) 282-3896- Associates: Robb Burlage, Susan Reverby, Morgantown, West Virginia; Constance Bloomfield, Desmond Callan, Kenneth Kenneth Kimmerling Kimmerling, Marsha Love, New York City: Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island. 1973. 2 within HMO's, care will be fragmented as long as specialists so heavily outweigh the number of general providers of care. HMO's can do nothing to attract doctors and other health personnel to rural and ghetto areas. HMO's will not open their doors to people unable to pay. And evi- dence suggests that even when lower in- come people are insured, they have a far harder time getting care from the HMO than does the middle class. Finally comes the myth of health main- tenance - that it's cheaper for an HMO to prevent disease than to cure it. In the short run, that's just not true. Annual Pap smears, breast exams, blood pressure checks, glaucoma screening and other valuable early diagnostic procedures cost money and require more medical person- nel. The sovings - in reduced numbers of seriously ill patients - come only many years later (if then), far beyond the pro- jections of corporate accountants and planners. Only with large federal grants has Kaiser offered multiphasic screening exams to many of its subscribers, and with cutbacks in the grants, Kaiser is re- ducing the screening. In HMO's as within " mainstream " medicine, acute illness will always take precedence over preventive care. People who believe that HMO's should be publicly controlled - and _ service - ori- ented rather than privately - run and profit- oriented have two courses of action. They can try to set up local health plans pub- licly controlled by the users and em- ployees. Community groups across the country are planning or even actually es- tablishing their own HMO's or PHP's. But the capital requirements needed to start, and the enormous time and energy spent on technical proposals, plans and con- tracts are almost prohibitive. It is the rare community that will put together a plan that it really controls without being in- debted to a lending institution or a group of doctors. The alternative is a struggle for areas of power in private HMO's - for community positions on the board, for em- ployee meetings in specific clinics and hospital wards, and for public airing of planning documents and financial trans- actions. In either case, HMO's will in- creasingly be foci of community and health worker action in the health system. STATEMENT REQUIRED BY THE ACT OF AUGUST 12, 1970: SECTION 3685, TITLE 39, UNITED STATES CODE, SHOWING THE OWNERSHIP, MANAGE- MENT AND CIRCULATION OF THE HEALTH - PAC BULLETIN. 1. Title of Publication: Health - PAC BULLETIN. 2. Date of filing: September 28, 1973. 3. Frequency of issue: 8 times a year, January, Febru- ary, March, April, May, September, October, November. 4. Office of Publication: 17 Murray Street, New York, New York 10007. 5. General business office of publishers: 17 Murray Street, New York, New York 10007. 6. Publisher: Health Policy Advisory Center, Inc.; Edi- tor: Howard Levy, c / o Health - PAC, 17 Murray St., N. Y., N. Y. 10007; Managing Editor: Ronda Kotelchuck, c / o Health - PAC, 17 Murray St., N. Y., N. Y. 10007. 7. Owner: (If owned by a corporation, its name and ad- dress must be stated and also immediately thereunder the names and addresses of stockholders owning or holding 1 percent or more of total amount of stock. If not owned by a corporation, the names and addresses of the individual owners must be given. If owned by a partnership or other unincorporated firm, its name and address, as well as that of each individual must be given.) Private, non profit - membership corporation: Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Members: Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Louise Lander, Howard Levy, Nancy Jervis, Judy Carnoy, Tom Boden- heimer, Elinor Blake. 8. Known bondholders, mortgagees, and other security holders owning or holding 1 percent or more of total amount of bonds, mortgages, and other securities: None. 9. For optional completion by publishers mailing at the regular rates (Section 132.121, Postal Service Manual) 39 U.S.C. 3626 provides in pertinent part: No " person who would have been entitled to mail matter under former sec- tion 4359 of this title shall mail such matter at the rates provided under this subsection unless he files annually with the Postal Service a written request for permission to mail matter at such rates. In accordance with the provisions of this statute. I hereby request permission to mail the publication named in Item 1 at the reduced postage rates presently authorized by 39 U.S.C. 3626. Signed, Ronda Kotelchuck, managing editor. 10. For completion by nonprofit organizations authorized to mail at special rates (Section 132.122, Postal Manual). The purpose, function, and nonprofit status of this organi- zation and the exempt status for Federal income tax pur- poses have not changed during the preceding 12 months. 11. Extent and nature of circulation: average number of copies each issue during preceding 12 months: total number of copies printed (net press run, 4,000; paid cir- culation: (1) sales through dealers and carriers, street vendors and counter sales: 0; (2) mail subscriptions: 2,200; total paid circulation: 2,220; free distribution by mail, carrier or other means: (1) samples, complimentary, and other free copies: 292; (2) copies distributed to news agents, but not sold: 128; total distribution: 2,620; office use, left over -, unaccounted, spoiled after printing: 1,380; total: 4,000. Actual number of copies of single issue published near- est to filing date: Total number of copies printed (net press run): 4,500; total paid circulation: 4,500; sales through dealers and carriers, street vendors and counter sales: 0; mail subscriptions: 2,243; free distribution by mail, carriers or other means: (1) samples, complimentary and other free copies: 183; (2) copies distributed to news agents, but not sold: 88; total distribution: 2,514: office use, left over -, unaccounted, spoiled after printing, (held in office for future orders): 1,986. Total: 4,000 I certify that the statements made by me above are correct and complete, (signed) Ronda Kotelchuck, manag- ing editor. 3 CORPORATE MEDICINE: THE KAISER HEALTH PLAN " I want to see a thousand of these health centers all over the country, " declared Henry J. Kaiser in 1950. Well, it would. warm Henry J's gravestone if he knew that today his name is linked with the most important health care reform in a troubled America. The Kaiser Permanente - medical care program operates through- out most of California, up to Portland, out to the Hawaiian Islands, into Denver and east to Cleveland. Kaiser Permanente - (K - P) has its propo- nents and its critics. K - P, which is group- practice based, has stopped hospital over- utilization and cut costs, supporters claim. Critics counter that Kaiser provides " as- sembly - line medicine " and, because it cuts costs, care is mediocre. Many Cali- fornia subscribers think " Kaiser's not good, but it's the best around. " Kaiser certainly differs dramatically from traditional American medical care. People buy insurance from the Kaiser Foundation Health Plan usually through their union or place of employment. But the insurance is good only for care of- fered at K P's - own hospitals and clinics. When Kaiser members get sick, they call the nearest Kaiser facility and make an appointment - with their personal phy- sician if they have one, or frequently with whatever specialist seems appropriate. Be- cause appointments are often hard to get, people needing immediate treatment can go to the drop clinic - in - or emergency room. Those desiring a physical check - up are referred to the multiphasic screening unit for a battery of tests with a follow - up doctor visit. Generally Kaiser covers many more medical services than most private insurance, and leaves fewer deductibles and other out pocket - of - payments for the patient. Another important and innovative feature at Kaiser is that doctors are paid on a salaried rather than fee service - for - basis. While Kaiser administrators and _ re- searchers have written extensively about Kaiser's positive achievements, a critical study is needed to sort out the successes from the failures and to address certain questions: Why is a large corporation like Kaiser Industries, traditionally engaged in construction, mining and aerospace, as- sociated with a health plan? Is K P - really non profit -? Does it truly keep down the costs of medical care? And how do its subscribers feel about the care they receive? Kaiser Permanente's - Beginnings Kaiser Permanente - sprouted in a field of cement: the colossal dam construction of the'30's. Hoover, Grand Coulee and Bon- neville dams were all built by Kaiser In- dustries under government contracts. In 1933, more than 5,000 Kaiser workers were cutting a canal to carry fresh water from the Colorado River's Hoover Dam to Los Angeles. The project spread over 400 square miles of desert, and injuries or sickness meant a 200 mile - trip to Los 4 Angeles. Because of the distance, Kaiser built medical facilities in the nearby area. Henry Kaiser made an agreement with Sidney Garfield, an enterprising young doctor in Desert Center, California, to set up a prepaid medical service. Initially, Kaiser paid the Desert Center Hospital and physicians a certain amount to cover industrial injuries. Later, the workers could voluntarily put in a nickel - a - day payroll deduction for general medical services. When Kaiser moved on to the Grand Coulee Dam project, Garfield followed and continued his prepaid medical plan. For the first time, workers'families were given full medical coverage, wives for seven cents a day and children for twenty - five cents a week. The Government Helps Out At the onset of World War II the market for dams slackened, and Henry Kaiser turned to shipbuilding. Again using gov- ernment contracts, Kaiser organized ship- yards in California, Oregon and Wash- ington, employed 200,000 people, and turned out fully 35 percent of all US mer- chant vessels made during World War II. As a result, Henry I was dubbed by many as " Sir Launchalot. " These shipyards were the basis for the first expansion of the Kaiser medical em- pire. In order to keep his men healthy, Henry Kaiser built clinics at production sites in Oakland, Richmond, Vancouver and at the Kaiser steel mill in Fontana, California. " The financing of these clinics was provided out of government contracts, since their cost was accepted by the au- thorities as a bona fide operating expense. After the war the clinics and their equip- ment were declared surplus war property. The Kaiser Hospital Foundation was es- tablished by Kaiser and his wife, Bess, to buy them at 1 percent of cost. " (1). With the shipyards closed and the Kaiser workforce plummeting, the health plan was opened to the public and re- named the Kaiser Permanente - Plan. (The name Permanente was Bess Kaiser's idea; Henry's first cement plant was lo- cated on the Permanente Creek.) Thus at government expense, the K - P medical care plan was begun. Henry Kaiser's Philosophy Henry Kaiser's expansion into the health field wasn't just " one of his crazy ideas, " as many critics thought. During the New Deal years, the air was filled with federal and state proposals advo- cating compulsory health insurance. This movement was strongest in California where over a dozen progressive health bills were introduced during the late ' 30's and'40's. A strong advocate of private enterprise, Henry Kaiser in 1942 publicly warned, " If the doctors fear socialized medicine, if industry is anxious about the widening powers of the state, why not venture now, boldly, into the activity that will forestall the superplanners in their schemes to di- rect medical services into the channels of distributive bounty? " (2) In 1945, Henry Kaiser began a national campaign for his new protoype of health insurance. He modestly proposed that the Federal Housing Agency guarantee 10 percent of local bank loans to non profit - groups that wanted to set up facilities for prepaid hospital care. The AMA called Kaiser's program " socialized medicine. " Kaiser countered that his prepaid medical projects would operate as " business en- terprises motivated by the impelling force of competition. " (3) But Kaiser did not need any legislation. His visions came true much faster than people expected. By 1955, K P - had over 500,000 subscribers. Kaiser Is Big Business Whether Kaiser physicians or sub- scribers like it or not, Kaiser Permanente - is part of the Kaiser Industries empire and is largely controlled by it. Kaiser Indus- tries consists of about 100 active com- panies including Kaiser Aluminum and Chemical, Kaiser Steel, Kaiser Cement and Gypsum, Kaiser Engineers and Kaiser Aerospace and Electronics. Of the 17 persons on the board of di- rectors of the Kaiser Foundation Health Plan and Hospitals, eight represent Kaiser Industries. Most prominent is Henry Kaiser's son, Edgar, who is chairman of the board of both organizations. Kaiser Industries'representation on K - P was even stronger a few years ago, but as K - P be- came more successful and secure in its West Coast position, it began responding to public pressures of the'60's and added non Kaiser - people with little power. As public relations man Dan Scannell quip- ped, " Now we have a Black, a woman and an Oriental on the board. " Many people ask why a _ successful 5 business would want to get involved with all the problems of health delivery. Dr. Clifford Keene, president of the Hospitals and the Plan, as well as a board member of Kaiser Industries, sums it up in saying, " the unparalleled corporate interest in health and medical affairs... arose out of the needs and interests of the Kaiser companies over the past 30 years. " (4) We can only speculate what these needs and interests are. Washing Away Industry's Sins As California labor consultant Thomas Moore puts it, " the medical program is just so damn self serving - for Kaiser Indus- tries. It washes away the sins of industry. " Health care is always a shining star to pin on one's chest. When asked in inter- views which of his ventures gives him the most satisfaction, Edgar Kaiser always re- sponds, " the Kaiser Medical Care Pro- gram. H " Tomorrow the World The Kaiser medical philosophy has not stopped at the American border, but is expanding throughout the world. Located on the 17th floor of the giant Ordway Building (part of the Kaiser Center) in downtown Oakland, a small staff is quietly spreading the word throughout the Third World under the guise of the Kaiser Foundation International funded (KFI) by Kaiser Industries. KFI was originally organized in 1957 as a California non profit - corporation under the name of Kaiser Foundation of Hawaii. According to KFI's literature, its original purposes were to develop charitable, scientific, educational and hospital programs on a local basis. But in 1964, its emphasis had shifted to pro- moting hospital and health care programs abroad. Reflecting its potential geo- graphical scope, its name was changed to Kaiser Foundation International. Its board of directors include Dr. Clifford H. Keene, president, who is also director of both Kaiser Industries and the Health Plan and Hospitals, and vice president - Dr. James P. Hughes, also a director of Kaiser Industries. KFI is naturally following in the footsteps of its parent organization, the Kaiser Health Plan and Hospitals. Initially it was active only in those countries (Jamaica, Ghana, etc.) where one or another of the various Kaiser industrial and construction firms had business interests. The Foundation has organized and managed mostly occupational medical services for its employees - espe- cially its foreign workers - located in remote areas. " In Ghana. " according to Dr. Hughes, " it was quite clear that our medical mission at the outside would be to take care of the work injuries on the construction of the plant, so that the local government facilities would not be further burdened... Our second consideration was that we had recruited a group of skilled people from around the world to go in and provide the technical know - how that the construction required. We knew that they would not go there, at least happily, without an adequate medical service. So there was no problem at all about identifying for whom we would be responsible at the outset, and to what extent. " (Our italics.) (Health Care For Remote Areas, An International Conference, Kaiser Foundation International, 1972, page 21.) It's all very good for companies to provide health care facilities, but KFI is taking a giant step in developing its brand of medical delivery services for other countries. As a matter of fact, according to Hughes, " the majority of de- veloping countries in which Kaiser Foundation International has worked to date have not been the site of Kaiser industrial or construction projects.... The mission that we in Kaiser Foundation International are charged with is to find places around the world where community health care can be improved by applying some of the principles developed in our domestic prepaid health plan. " 6to On Edgar's conscience may be the fact that Kaiser Steel is one of the big polluters in southern California. Edgar Kaiser con- tributed sizeably to the campaign against California's recent ecology measure, Prop- osition 20. According to the Washington Post (5), Kaiser Aluminum dumps large amounts of mercury containing - waste into the Mississippi River in Louisiana. Con- troversy erupted in the San Francisco Bay Area over Kaiser Sand and Gravel's de- facing of hilltops in Orinda. Other Kaiser strip mining operations go on in Canada and Australia. Another blot on Kaiser Industries'image is its rating in the top 100 Department of Defense contractors'list. One of its wholly - owned subsidiaries, Kaiser Aero- space and Electronics Corporation, pro- duces rocket motor nozzles and structural components for aircraft and missile pro- grams and electronic equipment such as aircraft flight display systems. In 1972, Kaiser Aerospace and Electronics had a 9.7 $ million contract to build electronic equipment for the A 63 - fighter bomber - which was used extensively over Viet- nam. Kaiser companies also have made bombers, ammunition and built military bases (6). Kaiser Aluminum and Chemical, in a new partnership with Aetna Life and Casualty Company, is one of the coun- try's largest real estate and land develop- ment corporations. Directed by Edgar Kaiser, Kaiser - Aetna has developments in California, Hawaii, Arizona, Baltimore, Atlanta, Cincinnati, New Orleans and Texas. In 1970 it evicted over 100 poor na- tive Hawaiian families at Kalama Valley. In a Wall Street Journal ad, Kaiser - Aetna boasts, " If we're not already in your neighborhood, perhaps we will be soon.'" Nor is Kaiser above self serving - illegal deals. The Wall Street Journal (7) reported that 36 officers of Kaiser Steel, including Edgar Kaiser, secretly bought 63,200 shares in a Canadian coal mine. The shares were supposed to be sold only to Canadians. When the mine yielded prac- tically nothing, the Kaiser officers, with inside information, sold their shares at a profit while making reassuring statements about the mine. The Securities and Ex- change Commission investigated, and a federal court issued an injunction against Kaiser's fraudulent activities. A Kaiser public affairs vice president - commented, " Everything we've done is open and above board. " Kaiser and Taxes In 1948, Henry Kaiser set up the Kaiser Family Foundation which is entirely dis- tinct from the Kaiser Foundation Health Plan. In doing so, Henry " seemed more interested in providing a vehicle for tax planning and estate management than in execution of a charitable program, " ac- cording to a study by the usually staid Twentieth Century Fund (8). In fact, the Kaiser Family Foundation, the 27th largest foundation in the US, plays a key role in the control of Kaiser Industries by mem- bers of the Kaiser family. The Kaiser Family Foundation is now the single largest owner of Kaiser Indus- tries stock, with a controlling share of 32.7 percent. The next largest block of stock, 8.5 percent, is owned by Edgar Kaiser, chairman of the board of Kaiser Industries. Currently, Edgar is also a trustee of the Family Foundation. The Family Foundation's income from Kaiser Industries'stock is tax free -. So Edgar can make a large, taxable personal income from his own shares, and keep control over Kaiser Industries through the tax free - Family Foundation shares. Specifically, the Family Foundation pro- vides capital to the Kaiser Foundation Medical Care program to assist its ex- pansion in California and into new re- gions of the US (9). The Foundation donated $ 3.5 million to start a Kaiser- Permanente program in Cleveland, and $ 2 million for one in Denver. Seed money for the Oregon and Hawaii ventures also came from the Foundation. To insure that control of the Family Foundation never leaves Kaiser hands, all of the trustees of the Family Foundation are past or present members of the boards of both Kaiser In- dustries and Kaiser Permanente - . (Interest- ingly, for a while K - P directly owned $ 2 million of Kaiser Industries stock, but sold its shares in 1970.) The Family Foundation has received most of its stock from be- quests in the wills of Kaiser family mem- bers in 1951 after the death of Bess Kaiser, in 1961 after the death of Henry's youngest son, and in 1967 following the death of Henry himself. Kaiser Industries also receives a small, but direct benefit from K P's - continuous hospital and clinic construction. Kaiser Engineers, a wholly - owned subsidiary of Kaiser Industries, designs most of the hospitals and many of the materials used for construction are Kaiser's. One example comes from Redwood City, California 7 where a building inspector explained, " Of course Kaiser Industries builds their hospitals, and they specify in their con- tracts that it uses their own materials. " ' (10) Kaiser's Growth " Growth is a way of life for the Kaiser- Permanente Program, " states the K - P 1969 annual report. Most subscribers don't even know that 4 percent of their premium plus a minimum of 15 cents per member per month is budgeted for expansion. K P's - eagerness to grow is reflected in its over subscription - policy in some re- gions. The southern California Panorama City Hospital provides a good example. Three years ago, the Lockheed Corpora- tion in Burbank was looking for a health plan for its 8,000 employees. Kaiser ini- tially said that it wasn't equipped to handle that many more people for three years. But not wanting to lose the 3.3 mil- lion dollars a year that 8,000 employees would bring in, Kaiser changed its mind when Lockheed began to look elsewhere. The Lockheed employees were not as- signed their own doctors until they were processed through a screening exam. But appointments for the exam took up to six months and even then, the members did not receive a doctor unless they showed an abnormal test. The discrepancy in staffing for the new patient load was not fully rectified for three years. According to one source, the entry of Lockheed em- ployees resulted in other Kaiser members getting lower quality services for their money, the new Lockheed workers getting partial benefits even though they paid full price, and hospital personnel working longer and harder hours with no increase in pay. Why does K P - expand? One important reason was expressed by a K P - planner: " As long as we keep expanding, our pa- tient population won't get too old. If we remain static, our average patient's age will get older and older and then we'll be in trouble economically. This way every time we get a new union or a new factory, we get only the people who are working now and are in good health; not the re- tirees and the people who've had to quit because of a disabling disease. " (11) This is good " business sense, " because the older one gets the more medical services are required. Also at Kaiser, the longer one is a member, the easier it is to know and utilize the system. As one Kaiser 8 nurse explained, The " longer you're at Kaiser the more you realize that you can get immediate care by demanding and shouting either on the phone or in the clinics. " Clearly, it is more economical for Kaiser to have a continuous stream of new subscribers who don't know how the system works. How The Kaiser Health Plan Works Who Subscribes? Two and a half million people belong to Kaiser. The Northern and Southern Cali- fornia regions each account for well over a million, with the remaining 300,000 scat- tered in Oregon, Hawaii, Ohio and Colo- rado. Yet, as Kaiser's own analysis shows, its membership by no means re- sembles the general population (12). Kaiser families had an average income of 11,309 $ in 1967 and 1968, while data show southern California families aver- aging incomes of $ 10,421. Thus Kaiser tends to enroll healthier people avoiding the burden of those who need medical care the most - the chronically ill, elderly and poor. In the words of Kaiser's own economists, " we are younger and rela- tively under represented - in certain popu- lation groupings, for example, the unem- ployed, the indigent, the wealthy, the self- employed, and people living in rural and other non metropolitan - areas. " 14 () It should be noted that Kaiser is no different than private insurance companies in skim- ming lower - risk people from the popula- tion; commercial insurers in southern California, for example, have an even younger and healthier population than Kaiser. In northern California 76 percent of Kaiser members are in a healthy age group under 45 years, compared to 70 per- cent of the general population (13). Only 4.2 percent of Kaiser subscribers in north- ern California are over 65, whereas 9 percent of the general population is in this high risk age. Kaiser will not accept group enrollment that has more than 25 percent of its membership over 60 years. If it weren't for Medicare, Kaiser would have far fewer elderly people. In northern California 87 percent of members join K - P through a group, with the employer generally paying all or part of the monthly charges. Public employees -federal, state, local, including em- ployees of school districts constitute - K P's - Business K - P is a very successful business operation. Although it is legally a non profit - organization, its " excess income " is as high as many profit making - corpora- tions. In 1971, K - P reported a free tax - net income of $ 12 million. Adjusting that figure for accelerated depreciation, and for corporate income taxes, Fortune claims that the organization's excess income would be 8.8 percent. This is about equal to that of the oil industry (9 percent) and only 0.3 percent below the average return for the Fortune 500 that year, according to Fortune. An indication of Kaiser's financial strength is its ability to borrow from the Bank of America at the prime rate. In January, 1973, Standard and Poor's awarded the Kaiser Plan an " A " bond rating - its first to a private non profit - corporation. Because of its legal non profit - status, K - P cannot pocket its profits. Much of its excess income is turned back into expansion and high administrative salaries and expenses. The total revenue of K - P in 1972 was $ 454 million. Of this amount, $ 363 mil- lion came from members'dues; 44 $ million from supplemental charges (most of which comes from the pharmacy and the optical laboratories); $ 37 million from Medicare reimbursement, and $ 10 million from non plan -, industrial and non member - services. Expenses for 1972 were $ 441 million with $ 234 million going to physicians and their staff; $ 151 million going to hospital services including - the salaries of all hospital workers: 28 $ million for outpatient pharmacy and optical serv- ices and almost $ 4 million for other benefits such as ambulance costs and reim- bursements of members for area out - of - emergency expenditures; close to $ 7 million goes to Community Service programs, but almost all of the $ 7 million is reimbursed under federal research grants and contracts; and $ 13 million is used to administer the Health Plan. more than 40 percent of Kaiser's total membership. Non group - enrollment is 13. percent of Kaiser's entire membership. These persons enrolled on an individual basis or converted to individual member- ship when they left an employer who had Kaiser insurance. According to Kaiser spokesman Robert Zimmerman, the health plan will not accept high - risk individuals. who are over 60 or have high blood pres- sure, diabetes or other chronic conditions. Benefits under individual enrollment are more limited than those provided in groups and the premiums are higher. The health plan may terminate the member- ship of individual members on 15 days. notice. Officials say this is seldom done. Comprehensive Benefits Kaiser's benefits are relatively compre- hensive compared to other health insur- ance plans. Generally all subscribers re- ceive hospital services, out patient - care with lab tests and X rays -, drugs, eye exams, physical therapy, ambulance serv- ice, emergency care and maternity care (after 10 months of membership). How- ever, different members have different plans, depending on the costs of the monthly premiums. A more expensive plan might include psychiatric service and long term care; a cheaper plan might charge the patient for certain services and limit the number of hospital days. In southern California, for example, Plan AA costs more per month and pro- vides doctor visits, eye exams, and physical therapy free. Plan BC, with a lower monthly premium, charges $ 2 per doctor visit, eye exam and physical ther- apy treatment. Both AA and BC sub- scribers must pay " reasonable rates " for out patient - drugs. Plan M for - Medicare beneficiaries - is the most comprehensive; Kaiser receives a monthly payment from the federal government plus an additional charge from the member for those services not covered by the government. Currently the health plan does not cover attempts at " suicide or other inten- tionally self inflicted - injuries or illnesses (this would include overdosage of pills); 9 ~ Structure of the The Kaiser Permanente - medical care program is divided into four components: the Kaiser Foundation Health Plan, Kaiser Foundation Hospitals, Permanente Medical Groups and Permanente Services Incorporated. All four are decen- tralized into six regions. The Kaiser Foundation Health Plan This " profit non -" corporation acts like an insurance company. The main dif- ference between it and Blue Cross is that people insured by the Health Plan must (except in emergencies) use their insurance only at Kaiser hospitals with Permanente Medical Groups. So the Health Plan not only enrolls subscribers, it also arranges for their health services through contracts with the hospitals and medical groups. The Kaiser Foundation Hospitals The hospitals, also " profit non -" , are run by the same board of directors as the Health Plan; in fact, these two components have almost amalgamated into one entity. Kaiser has over 20 hospitals, and the Health Plan contracts with non Kaiser - hospitals in Cleveland, Denver and San Diego where the program has relatively few subscribers. The Permanente Medical Groups (PMG's) The PMG's are groups of physicians, one in each of the six geographical regions. Legally they are profit making - organizations, though the profits go to the physicians themselves rather than to outside stockholders. The PMG's are separate from the Health Plan and Hospitals partly because of state laws that prohibit physicians from working under a lay employer, and partly in order to maintain the non profit - , tax exempt - status of the Health Plan and Hospitals. Structurally, the PMG's each have their own board of directors (sometimes called executive committee). The Health Plan pays the PMG's on a capitation basis, that is to say, the PMG receives a fixed amount of money per member per month. In operation drug addiction; alcoholism; conditions covered by Workmen's Compensation; military - service connected conditions; cus- todial, domiciliary or convalescent care; cosmetic surgery; corrective appliances and artificial aids; extensive neuromuscu- lar rehabilitation and conditions resulting from a major disaster or epidemic. " Also, if a member is injured or taken ill while temporarily more than 30 miles from a Kaiser hospital, Kaiser will pay for treat- ment in any hospital. Kaiser claims it will pay up to an aggregate maximum of $ 3,000 for emergency services and ambu- lance. There have been reported cases of emergencies, where Kaiser has not paid because it didn't deem certain injuries or illnesses as emergencies. Subscribers suf- fering emergencies within the 30 mile zone must go to Kaiser or pay their own way. In northern California, new benefits will 10 be added, effective January 1, 1974. They are: care for intentionally self inflicted - in- jury (this apparently is included because at point of entry, it is difficult to diagnose whether certain injuries or medical condi- tions are inflicted self -) ; intensive care for TB patients in specialized hospitals (there is a low incidence of TB among Kaiser subscribers); emergency coverage up to $ 3,000 occurring anywhere in the world (including 80 percent coverage up to $ 50,000 and 365 days in the hospital). Low Income - Care By dabbling in small projects for low- income people and publicizing these proj- ects far beyond their worth, Kaiser is try- ing to change its middle - class image. The best known - effort is the Portland OEO pro- gram for 1,200 low income - families. Simi- lar tiny programs were opened in south- ern California and Hawaii. Kaiser is K - P Medical Program this basically means that physicians are salaried. Salaries of Kaiser physicians are competitive with the medical marketplace. Beginning salaries range from $ 20,400 to 24,000 $ with fringe benefits up to an | additional 25 percent. The average salary is around $ 40,000 plus substantial fringe benefits. According to PMG physicians, some specialists make $ 70.000 to $ 100,000. Each year besides living cost - of - increases, merit raises are doled out by department heads and the physicians - in - chief. For the first two years a doctor at Kaiser is an employee of the PMG, after which the physician is eligible to become a so called - " participant. " After another year, the physician is eligible for partnership. The difference between a partner and a non partner - appears to be primarily financial. Once a partner, the doctor can share in all the profits of the group. Voting privileges are also acquired. Approximately thirds two - of Kaiser's more than 2,000 physicians are partners. Doctors'profits at Kaiser are variously termed the " contingency contractual payment, " " divisible surplus, " " bonus " or " incentive compensation. " What this means is that after the budget for the entire medical care program (hospitals and PMG's) is prepared, an additional 5 percent is tacked on and made part of the final budget. Then, four or five times a year, any budgeted money left over is distributed equally between the PMG's and the Health Plan Hospitals / . The PMG money goes to the physician partners as a bonus, and usually runs from $ 7,000 to $ 9,000 in addition to their salaries. Permanente Services Incorporated (PSI) The profit making - Permanente Services corporations - one for each region- perform administrative and pharmacy services for the Hospitals and PMG's. PSI functions include accounting, payroll. employee relations, planning and construction management, and the operation of pharmacies for the hospitals and clinics. The profits of PSI go to its stockholders, the Kaiser Foundation Health Plan and Hospitals. PSI appears to be separate from the Health Plan and Hospitals for legal and tax reasons. rightfully proud of the fact that the poor were cared for on an equal basis with regular Kaiser subscribers. Of course. Kaiser received ample funds for its proj- ects; in addition to paying the premiums, OEO provides money for patient transpor- tation, home care, staff training and other social and outreach services. You can bet that these extras will disappear with OEO. Without investing a penny of its own, Kaiser found through its OEO programs that it could serve small numbers of poor people without a marked increase in costs per patient (15). This information is ex- tremely useful in deciding on further in- tegration of low income - Medicaid patients into Kaiser facilities and calculating reim- bursement rates from Medicaid programs. In an experiment with a prepaid Medi- Cal (California's Medicaid program) con- tract, Kaiser's southern California Fontana facility signed up 1,200 Medi - Cal patients in 1972. This contract may not last. Under a new conflict of interest law, no organiza- tion can receive Medi - Cal contracts if any of its officers are state employees, legisla- tors or commissioners. K - P may prefer ac- cess to important government groups than to serve low income - patients. Charity Begins At Home A very small number of the medically indigent people without insurance, Medi- care or Medicaid - get into Kaiser. On the average, according to a Health Plan rep- resentative, only 1 percent of any one hospital's inpatients are non Plan - sub- scribers and have no insurance coverage. They are financed by the individual facil- ity's Medical Social Assistance Account. In the past the percentage of charitable cases was much higher. The 1961 K P - Annual Report dedicated a page to chari- table care nobly stating, " The Com- 11  munity Service Program places special it is available, acceptable, compre- emphasis on charitable care.... This hensive, continuous, and documented; charitable care program is designed to as- sist persons or families the social service workers describe as'medically indigent. ' They become'medically indigent'in the face of heavy hospital or medical bills. ... Any clergyman, community welfare agency representative, doctor or nurse may refer these'medically indigent'cases to Kaiser Foundation Hospitals. " and the extent to which adequate therapy is based on an accurate di- agnosis rather than symptomatology. I would add the criterion of dignity- the dignity accorded the recipient of services, and the dignity of style of the providers of services. " (19) Availability Today Kaiser is far less generous with community services and rarely talks about the individual medically indigent. The community service funds allotted for " charity, research and education " are largely funneled to physicians for indi- Almost everyone agrees that the US suffers from a shortage of doctors. But no one is sure just what the proper ratio of physicians to patients should be for op- timal care. Kaiser views one physician per 1,000 members as the ideal, but does vidual research projects. This arrange- ment enables Kaiser to create a " uni- not achieve its goal. In fact, Kaiser's phy- members sician - to - ratio is lower than the versity atmosphere " for many of the " aca- demically inclined " doctors. As one San physician / patient population ratio of the states in which Kaiser is located. The ratio Francisco doctor said, " research money is our sanity money. It gives us a half day or so to be away from patient care. " Quality of Care The most important aspects of medical care are most difficult to measure. Only a few studies of Kaiser's quality of care have been done. Most useful are (1) a 1972 study by Milton Roemer and others on comparative utilization rates, costs, at- titudes of patients, and quality of care under three major types of health insur- of para medical - personnel to patients is also lower at Kaiser, which employs an estimated two persons per patient com- pared with 2.8 nationally in " short - term hospitals. " Doctors per 100,000 Population - 1969 (20) State Ratio Percent K - P Ratio Difference Northern California 161 102 -36 Southern California 161 90 -43 Hawaii 133 83 -38 Oregon 128 67 -49 ance plans (Blue Cross / Blue Shield, pri- vate insurance company and Kaiser) (16), (2) an examination by Nolan, Schwartz and Simonian of social class differences in the utilization of pediatric services at the Oakland Kaiser clinic (17), and (3) the California Council for Health Plan Alternatives (a union sponsored - organiza- tion) and the Medical Committee for Hu- man Rights 1973 mail questionnaire study of consumer satisfaction among 10,000 members of the Northern California Car- penters Union who subscribed to the Kaiser Plan. (Because only 24 percent re- plied to the questionnaire (18), this study must be viewed only as an indication of consumer feelings.) The findings of these studies will be dis- cussed below in analyzing whether K - P meets its own standards for quality care. Dr. Clifford Keene, as President of the Kaiser Foundation Health Plan and Hos- pitals, has stated, " the criteria for judging quality in Understaffing causes limited access for Kaiser subscribers. The usual complaint among Kaiser subscribers is waiting on the phone to make an appointment, wait- ing until an appointment is available, and waiting at drop - in and emergency clinics. Thirty percent of the CCHPA / MCHR re- spondents wait over one month for an ap- pointment, and 27 percent wait from one to two hours to see a doctor at a drop - in clinic. Another problem facing many sub- scribers is that they live too far from the nearest Kaiser facility. Among patients sampled at the Oakland pediatric drop - in clinic, Nolan et al found 22 percent of pa- tients making daytime visits and 53 per- cent of those making evening visits had a transportation problem (21). Lack of access causes many subscribers to seek, and pay extra, for care outside Kaiser's facilities. 55 percent of those who answered the CCHPA / MCHR question- naire have used non Kaiser - medical serv- medical care are the degree to which ices since joining K - P. 78 percent of these 12 people must pay for these outside services. Kaiser Plays The Numbers Game Roemer and his colleagues found that 12 percent of the services used by sub- scribers in a 12 month - period took place outside the Kaiser facilities. However, Kaiser's philosophy is one of effi- ciency and cost savings - , and all per- sonnel are guided by it. Physicians and clerks alike are pressured to per- form to their limits; patients and workers suffer as a result. there is no report on the number of sub- scribers involved. Certainly far more than 12 percent of the subscribers used these outside services. The Kaiser Plan has its own statistics which show even higher outside utiliza- The telephone appointment proce- dure is the crucial entry point into the Kaiser system. All calls for ap- pointments are handled at a circular central appointment desk around which sit a number of clerks. In the tion. A K - P consumer satisfaction study prepared by the Field Research Com- pany found that 44 percent of a southern California sample replied affirmatively that non Kaiser - physicians and non Kaiser - medical services had been used (22). center of the desk is a huge elec- trically controlled lazy Susan - filled with all the physicians'individual schedules so that each clerk can Kaiser officials discount this figure, stating that the survey did not ask whether the services were referrals by Kaiser physi- cians or whether these outside visits were handle any appointment for any pa- tient to any physician. This all appears rather efficient. So why do subscribers chronically com- plain about long telephone waits of up to an hour? The answer lies in Kaiser's " numbers game. " In northern California, Kaiser's ad- ministration has decided that each covered by another health insurance plan carried by the other spouse. Kaiser's ex- planations are not convincing. The statis- tics of outside use are relatively high and if a majority of them are due to referrals, then Kaiser is actually admitting that its services are inadequate. Furthermore, the CCHPA study just cited above contradicts Kaiser's statement that members who use appointment clerk should be able to handle 25 calls an hour or an aver- outside care are covered by other insur- ance plans. age of five and a half to six physi- cians'calls. The clerks find this im- When broken down by income, Roemer's study showed that families earn- possible to do. Doing their best, each clerk handles about 150 calls a day. The clerks not only care for the pa- tients'needs, but also shuffle calls to ing under $ 11,000 seek more out plan - of - care than do families earning over that amount, especially for maternity care. The researchers suggest that lower income other departments. It is almost as if families may go out of Kaiser more often Kaiser deliberately wishes to make " because of some dissatisfactions or t- access difficult. because they have not learned to'work If the appointment procedure is the system'efficiently... " (23). sometimes a problem for patients, it is also no joy for the appointment desk clerks. The supervisors of the appointment clerks, who realize that the administration's goals are un- realistic, attempt to do their best. Each supervisor has a panel with automatic counters and red lights which flash on and off. The panel shows how many calls have been taken every hour by each worker, how many have been lost (lost " " calls are patients who hang up in dismay), and how many are wait- ing at any particular moment. It is difficult for any Kaiser subscriber to " work the system, " but the general prob- lems of Kaiser come down hardest on peo- ple who have previously never been given the opportunity to navigate the health system. Kaiser's out patient - services are organized with a white, middle - class bias. Blue collar families utilize K - P services considerably less than do white collar families. Roemer showed that in a three month period, members of blue collar families made only 662 doctor visits per 1,000 subscribers, but for white collar fam- ilies the rate is 954 per 1,000 (24). Utilization also differs considerably be- tween whites and non whites - . Nolan re- ports that " more than half the visits made 13 by white children were to the appoint- ment clinics, but only one third - of the visits made by Negro... children were to the appointment clinics.... Slightly more white patients came for health su- pervision (school examinations) than for acute conditions... among Negroes, for every preventive visit there were two for acute conditions. " (25) Acceptability Kaiser members like the prepayment method of financing health care more than commercial plan holders like the fee- for service - system. But prepayment does not necessarily result in equal use of services by families or in equal sharing of costs. Non utilization - is actually an in- direct way of subsidizing the care re- ceived by the users of services. If there is a greater degree of non utilization - , as the Nolan and Roemer studies show, by lower income groups enrolled at Kaiser then they are subsidizing the upper income groups who use the services more ex- tensively (26). Attitudes toward medical care received at Kaiser are less positive than attitudes towards Kaiser's financing. K P's - own study, conducted by the Field Research Company, comes up with some startling figures: " In both past and present sur- veys, " according to Greer Williams, " only half of the members interviewed were sat- isfied with procedures in K - P clinics, such as getting appointments, promptness of service, and so on. " (27) Comprehensiveness Kaiser's benefits and coverage are com- prehensive when compared with other in- surance plans, although dental care is not covered and psychiatric services are limited. Kaiser covers a greater proportion of medical care costs than do other plans, but the coverage is by no means totally comprehensive. Studies show that Kaiser pays between 43 and 76 percent of total medical care costs (28). Continuity of Care Kaiser operates a dual ambulatory sys- tem of care: a patient can take the ap- pointment route or the drop - in route. The drop - in clinic is not integrated into the rest of the system. Patients go there pri- marily because they don't know how to use the appointment system or because they don't feel they can wait the days, weeks, or, for some specialties, even months to get an appointment. Frequent- 14 ly, these clinics (and especially night clinics) are staffed by moonlighting doc- tors. Drop - in clinics serve as pressure valves on an understaffed, overworked system. Without them Kaiser would have to hire more full time - physicians and ancillary staff; drop - in physicians are frequently part time - employees, not partners in the group practices. One reason care at Kaiser is discontin- uous is because specialty care is empha- sized, and is the core of the Kaiser design. Only half of Kaiser's physicians are clas- sifiable as primary care physicians (gen- eral practitioners, internists, pediatri- cians). The others are specialists or super- specialists to whom patients are referred for illnesses which often could be treated by a primary care physician. Although many Kaiser members are victims of discontinuous care, Black pa- tients fall overwhelmingly into this cate- gory. Nolan found that 48 percent of all white pediatric patients visited the drop- in clinic, while 67 percent of all Black pa- tients received care there. Furthermore, 18 percent fewer Black patients have a regu- lar pediatrician than do white patients (29). The CCHPA / MCHR study suggests that an even larger proportion of the total Kaiser population is without a family phy- sician. That study found 51 percent of re- spondents without a personal physician, of whom 71 percent expressed a desire to have one. What are Kaiser physicians'reactions to the lack of continuity? An intra hospital - critique at the Santa Clara facility in- cludes physicians'complaints of fraction- ated care due to overuse of the specialty clinics and poor screening techniques. They added that patients are scheduled to see a different doctor at each visit, even for routine appointment follow - up. More- over, they claimed, scheduling did not leave them enough time to see their pa- tients adequately. Some physicians dis- courage " difficult " patients from returning or punt " " them from one doctor to another. A major issue the physicians continue to wrestle with is the emphasis of Kaiser management on quantity rather than quality of care. As one physician explain- ed, " The system bases many things on numbers without qualifying these num- bers. The problem is pressure from the ad- ministration which engenders a crazy paranoid way about numbers. " Every month a data sheet with the count of patients seen in each department and facility in the Northern California re- gion is distributed to physicians - in - chief and department heads. Some doctors have been told by their department heads they were not seeing enough patients and shouldn't take educational leaves. Some doctors feel their schedules are so rushed and inflexible as to preclude de- livering adequate, humane care. The schedules are also nerve wracking - to many physicians, and, as one doctor put it, " they have an ultimately eroding ef- fect on a physician's sense of responsi- bility for the patient. " Democracy at Kaiser Membership Participation As far back as 1957, Henry Kaiser sum- med up K - P policy stating, " You don't ask your corner grocer to share his owner- ship with people who buy at the store. " Sixteen years later, K P's - attitude on mem- bership participation remains the same. There are no member representatives or representatives of subscriber groups on the national board of directors. In the late 1960's the unions attempted to get on the board; Kaiser flatly refused them. Thomas Moore, former executive di- rector of the California Council on Health Plan Alternatives. testified in 1971 before the Senate Subcommittee on Health, that, after two years of complaining about Kaiser's inadequate patient grievance procedures, K - P finally proposed some changes. Kaiser agreed to set up a griev- ance committee " as long as every patient bringing a grievance deposited $ 150 to cover the cost of arbitration.... " " To us, " explained Moore, " it is absurd to put such a heavy burden on a man who is making a complaint so that he can't afford to make it. " (30) Physician Participation K - P always emphasizes the democratic nature of the medical groups (See Box, Page 10) and their autonomy from the health plan. Kaiser considers it a " funda- mental principle that the physicians must be involved in responsibility for adminis- trative and operational decisions that af- fect the quality of care they provide. " Structurally the medical groups each have their own executive committee. Kaiser states it in its literature that " there is constant input from the partners, both formal and informal.... Key decisions are made not just by the board of di- rectors but by the board and the full membership. " (31) Interviews with physi- cians in the Northern California region about the decision - making process reveal a very different picture. One Kaiser doctor characterized the ex- ecutive committee as " an autocracy which makes decisions in the guise of'quality of care.'" Similarly a second physician called them " serving self - , power hungry men with coteries of syncophants who are building personal empires. " And a third Kaiser doctor described them as " an oli- garchy ruled with an iron fist that makes decisions by fiat. " Every day in one Kaiser physician's practice, a scheduling situation would arise in which " decisions were coming down from the top that in- terfered with how care was delivered. " (32) Within the last two years, with the attri- tion rate increasing significantly, the phy- sicians whose " opinions were neither sought nor listened to " were so dissatisfied that members of the executive committee were forced to tour the hospitals and tokenly restructure their committee. Today the committee's board, although it has changed from its original composi- tion of self appointed - lifetime members, is still not elected by or accountable to the full membership of the group. Now the committee consists of at least three old- timers whose power positions are un- shakeable, plus the physician - in - chief from each hospital, and one representa- tive from each clinic who is elected every two years by the partners of that facility. Only those representatives from groups of 25 doctors or more who have their own hospital are allowed to vote. (The physi- cians at the Sunnyvale Clinic and the South San Francisco Clinic, for example, are not voting members.) The company clique is still there; the physicians - in - chief are appointed by the executive committee and elected representatives are always outnumbered. Worker Participation If things are difficult for doctors, one can imagine the situation of hospital workers. Like all hospitals, Kaiser workers are not involved in any decision - making. The bulk of the workers at Northern Cali- fornia Kaiser, including LVN's (LPN's), pharmacists, technicians, dishwashers, housekeepers, etc., are members of Local 250 of the AFL - CIO, the Hospital and In- 15 stitutional Workers'Union. This fall Local 250 is negotiating a new contract with K - P. There are three areas that the union considers important: The first is wages. The union wants salary in- creases that will cover Bay Area cost - of- living increases. The second is health benefits. Kaiser gives its own workers Plan D coverage, which is not the most comprehensive. The union wants Plan SS, a better package. The third concern is that of working conditions. Some of the specific working conditions the union would like to see included, according to one union representative, are on job - the - training, career mobility, and lighter work loads. It should come as no surprise that the union considers this last issue to be the most difficult to negotiate with Kaiser. Utilization and Costs Many people praise and promote Kaiser for relative economies of costs and utiliza- tion of hospital services. Studies generally support the contention that economies ex- ist at Kaiser although the data are not entirely consistent. Four comparative studies are relevant Who's Who on the Board Edgar Kaiser Chairman - , Director of all Kaiser companies and subsidiaries. Clifford H. Keene, Board M.D. - of Directors, Kaiser Industries. E. E. Trefethan, Jr. Officer - on many Kaiser companies and President of Henry J. Kaiser Family Foundation. James A. Vohs Employed - by various Kaiser affiliated organizations; mem- ber of the Secretary of Health, Education and Welfare's Task Force on Med- icaid and Related Programs, 1968-70. Mary I. Bunting, President M.D. - Ex - of Radcliffe College; Commissioner with Atomic Energy Commission. Robert J. Glazer, President M.D. - of Kaiser Family Foundation; ex Vice - Presi- dent of Commonwealth Fund; Dean ex - of School of Medicine, Stanford University. Arthur J. Goldberg - General Counsel for AFL - CIO and United Steelworkers of America; Secretary ex - , U.S. Department of Labor; ex Associate - Justice of U.S. Supreme Court. William Colorado Grant - National Bank; Chairman Democratic State Central Committee, 1965-69; ex President - of Metropolitan TV Company: ex Chair- - man of the Board, Sangre de Cristo Broadcasting Company, Denver. William Hewlett - Chief Executive Officer and Director of Hewlett Packard - Corporation; Director, Chase Manhattan Bank and the Overseas Develop- ment Corp.: Trustee of the Rand Corporation; Member of the President's General Advisory Committee on Foreign Assistance, 1965-68; Trustee, Stan- ford University. Roy E. Hughes - Board of Directors of many Kaiser Industries Corporations. Henry M. Kaiser Edgar's - brother; Kaiser Glass and Fiber Corporation. George E. Link Director - of Texada Mines, Ltd., Minerva Bayovar, S.A., Kaiser Industries and Willys Motor, Inc. William Marks - Board of Directors of many Kaiser companies. Quigg Newton President - , Commonwealth Fund; Mayor, City and County of Denver, 1947-55; with Ford Foundation, 1955-56; President of University of Colorado, 1956-63; National Advisory Mental Health Council, National Insti- tutes of Health, 1964-68. Mitchell W. Spellman, M.D. Dean - of the Charles R. Drew Postgraduate Med- ical School. Arthur Weissman - Economist for Kaiser Health Plan. Ralph T. Yamaguchi - Assistant Public Prosecutor, City and County of Hono- lulu, 1937-39; Special Deputy Attorney General of Hawaii, 1938-39; Director, Hawaiian Telephone Company. 16 to this discussion: (1) Roemer, et al., Health Insurance Effects, 1972 (33); (2) The Federal Employees Health Benefits Pro- gram, 1971 (34); (3) The Report of the Med- ical and Hospital Advisory Council to the Board of Administration of the California State Employees'Retirement System (35); and (4) Family Medical Care Under Three Types of Health Insurance, Columbia University (36). Utilization Kaiser members have lower hospitaliza- tion rates compared with other groups when measured by total days of hospital care per 1,000 members per year. Kaiser's rate is lower in comparison with various commercial insurance plans and certain "'individual - practice type plans " such as the San Joaquin Foundation for Medical Care, and about half that of Blue Cross / Blue Shield (37). Two factors, the rate of Idmissions and length of stay per admis- ion, are responsible for Kaiser's lower ospitalization rates. Kaiser also has a much lower rate of ospital admissions for in hospital - surg- : al procedures, about one half - that of lue Shield. Specifically, the rate is sub- antially lower for tonsillectomies, " fe- ale surgeries, " appendectomies, and ill bladder surgery (38). Some authors suggest that one reason spitalization is lower at Kaiser than th other plans is because more proce- res are handled on an out patient - basis. wever, studies show Kaiser's rate of bulatory utilization does not differ atly from the rate in other plans (39). its On the average, Kaiser members do pay for the same benefits than members other health insurance plans (40). Al- igh premiums for Kaiser are often ter than for other plans, this is more . offset by smaller out pocket - of - inses. t families with incomes under $ 11,000 } higher out pocket - of - expenditures therefore greater total expenses than ies with incomes over $ 11,000. reas " higher income " families (over 00) have an average $ 49 out - of- et expenditure, " lower income " fam- average $ 112. This suggests that income families seek more care out- of Kaiser because of dissatisfaction ause they haven't learned to use the system (41). Although Kaiser is generally cheaper than other health insurance plans, it cer- tainly is not the answer to inflation. Kaiser's costs have inflated faster than the national average (the Consumer Price Index for Medical Care or " CPI "). For the ten year period 1960-70, the average med- ical care costs at Kaiser (premium and supplemental charges) increased approxi- mately twice as fast as the national aver- age (CPI). Yearly comparisons for this pe- riod show that Kaiser's costs increased more rapidly than the CPI in every year except 1964 and 1965 42 (). Were all med- ical care delivered through Kaiser - like plans, health care costs would continue their inflationary spiral. Cost Reduction and Patient Control In this society, medical services are like other commodities whose sale reaps profits. Producers / providers at once control the supply and create the demand for the product. Unnecessary goods such as too many specialists, drugs and surgery are foisted upon people while actual needs may go unmet. It is within this context that Kaiser's costs and utilization data must be considered. In prepaid group practices such as Kaiser, the traditional financial incentives are reversed so that profit or savings for physicians and hospitals alike can be achieved through minimizing, rather than maximizing, utilization of services. Given that there is unnecessary hospitalization and excessive surgery in " mainstream " medicine, Kaiser's lower hospital utiliza- tion and surgery rates are commendable. How does Kaiser achieve its lower utiliza- tion rates? The National Advisory Commission on Health Manpower, for example, rejects poor medical care, denial of services or relatively good health of members as ex- planations of Kaiser's cost savings - . The Commission also rejects as explanations both innovations in the practice of med- icine and economies of scale. They con- clude that pressuring the physicians to be cost conscious - and " avoiding waste " re- sult in savings. If the Commission is correct and control of physicians is a major source of the economies of Kaiser, several Kaiser doc- tors indicate that the methods and degree of pressure have an ultimately deleterious effect on the quality of care because of their negative effects on the physician (see quality of care section). 17 Furthermore, contrary to the Commis- sion's conclusions, it appears there are systematic mechanisms in the Kaiser sys- tem other than pressure on physicians which discourage utilization. Roemer and his colleagues discussed the deterring ef- fects of barriers created by the system's bureaucracy. And as a Comprehensive Health Planning official said, " Kaiser uses several recognized methods for deterring utilization: copayments, long telephone waits, inadequate waiting room size, shut- ting down hours of operation, requiring a series of tasks to obtain a prescription, and long waits for lab results. " (43) In terms of costs to members, Kaiser could economize in two ways. One is to reduce the " profits, " for example, by slow- ing expansion and eliminating the physi- cians'huge bonuses. The other is to re- duce the delivery of services. Kaiser is traveling the second route, one which can be followed only so far before quality of care is jeopardized. As a private business, K - P will never take the first route. Whether corporate HMO's develop in a significant way will depend on whether profits are made. If Kaiser is any indica- tion, the profits will be substantial. How- ever, problems in the delivery of health. care will remain. Others, such as over- hospitalization and excessive surgery may risk over correction - . With incentives for the extreme it is not unlikely for many people to go un hospitalized - who should be in hospitals. As seekers of health care, we will con- tinue to pay the costs: monetary, phys- ical and psychological. Budding HMO's will fight - out their survival in the arena of competition and the small weaker ones will fail because of the huge initial capi- tal investments. Ultimately health care will be delivered full force into the age of corporate capitalism. -Judy Carnoy, Lee Coffee and Linda Koo. Lee and Linda were summer interns at the San Fran- cisco office. References 1. 1. The Big Foundations, Waldemar Nielsen, 20th Cen- t2u4r5-y46 .F und Study, Columbia University, 1973. pages 2. Kaiser Wakes the Doctors, Paul de Kruiff, 1948. 3. Chicago Sun, June 20, 1945. 4. The Kaiser Permanente - Medical Care Program, A Symposium, Anne R. Somers, editor, The Common- wealth Fund, New York, 1971, page 13. 5. Washington Post, November 25, 1971. 6. DMS Market Intelligence Reports. 7. Wall Street Journal, January 5, 1972. 8. Nielsen, op cit., page 247. 9. Ibid., page 248. 10. See section 37.59 Kaiser Hospital General Specifica- tions, City Hall, Redwood City, California, February 15, 1966. 11. The Case For American Medicine, Harry Schwartz, 1972, page 174. 12. Somers, op cit., page 42. 13. Ibid., page 38. 14. Ibid., page 42. 15. Ibid., pages 138-148. 16. Health Insurance Effects, Roemer, Hetherington, Hop- kins, Gerst, Parson and Long, School of Public Health, The University of Michigan, 1972. 17. " Social Class Differences in Utilization of Pediatric Services in a Prepaid Direct Service Medical Care Pro- gram, " Nolan, Schwartz, Simonian, American Journal of Public Health, January, 1967. 18. Feelings About the Kaiser Foundation Health Plan on the Part of Northern California Carpenters and Their Families, April 5, 1973, CCHPA, 1870 Ogden Drive. Burlingame, Cal., 94010. 19. Somers, op cit., page 16. 20. Permanente Kaiser - Health Plan, Why It Works, Greer Williams, The Henry J. Kaiser Foundation, Oakland, Cal., 1971, page 38. 21. Nolan, et al, op. cit., page 48. 22. Williams, op. cit., page 40. 23. Roemer, et al, op cit., page 45. 24. Ibid., page 32. 25. Nolan, et al, op cit., pages 38-40. 26. Ibid., page 45. 27. Williams, op cit., page 48. 28. " An Evaluation of Prepaid Group Practice. " Avedis Donabedian, Inquiry, Vol. VI, Number 3, pages 1-15. 29. Nolan, et al, op cit., page 42. 30. Hearings Before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Part 4, page 1484. 31. Somers, op cit., page 91. 32. Personal Communication. 33. Roemer, et al, op cit. 34. The Federal Employees Health Benefits Program, 1971, studies utilization from 1961-68 in four different types of health insurance plans which were offered Federal employees and their families across the na- tion. The four types are group practice (seven plans, four of them are Kaiser), the Blues, commercial plans, and what they call individual - practice plans, such as the San Joaquin Foundation for Medical Care. 35. The Report of the Medical and Hospital Advisory Council to the Board of Administration of the Cali- fornia State Employee's Retirement System (The Sacramento Study), presents data gathered for 1962- 63 from California state employees who were mem- bers of the same four different types of health insur- ance plans as in the Federal study. 36. Family Medical Care Under Three Types of Health Insurance, Columbia University, 1962, compares the 1958 experiences of members of Kaiser in northern California, New Jersey Blue Cross - Blue Shield, and a commercial plan, General Electric, in the Midwest. A major drawback of this study is that the data are now 15 years old. 37. Footnotes 33, 34, 35. 38. The Columbia study found a similarly low rate for tonsillectomies at Kaiser, but found no differences in adult surgery rates. 39. Roemer, et al, op cit., pages 27-34. 40. Footnotes 33,34, 35. 41. Roemer, et al, op cit., page 45. 42. Financial Study of the Kaiser Medical Care Program, Working Paper Number 12, Robert A. Vradiu, David B. Starkweather, and Alfred W. Childs, University of California, Berkeley, Unpublished manuscript. 43. 43. Personal communication. INDEX (Dec. 30, 1973) A Abortion - Dec. '69, p.12; Mar. '70; Nov. '70, p.14; Dec. '70, p.9: Feb. '73, pp. 10-11. Addiction Services Agency -- June '70, p.9. Affiliations June '68; Aug. '68, p.5: Nov. - Dec. '68. p.14; Winter '69; Jul Aug.., '69, p.12; Apr. '69; Dec. '71; Sept. '73 (Montefiore - Prisons): Oct. '73 (Bellevue NYU -). Air Pollution - Oct. '70, p.10. 18 American Assn. of Foundations of Medical Care --- Feb. '73, p.8. American Assn. of Inhalation Therapists - Nov. '72, pp.4-5. American Association of Medical Colleges L Jul. - Aug. '69, p.4. American Conf. of Gov't. and Industrial Hygienists- Sept. '72. American Hospital Assn. - Nov. '72, pp.7-9. American Medical Assn. - Nov. '72, pp.3-4, 10-15. American Natl. Standards Institute Sept. '72. American Nurses Assn. - Nov. '72, pp. 8,11. : Asbestosis Mar. '73. Assn. for Retarded Children - Jan. '73. Attica Prison - Nov. '71; Sept. '73, pp.14-15 (Prison Health). B Feldstein, Martin - May '73, p.17. Fordham Hospital - Nov. - Dec. '68, p.13; Jul Aug. -. '69, p.9. Free Health Clinics - Apr. '71, p.6; Oct. '71; Feb. '72. G Bellevue Hospital - Sept. '73 (Prison ward); Oct. '73. Beryllium Poisoning - Sept. '72, p.13. Ghetto Medicine Bill Jan -. '70, p.11; Apr. '70, p.13; Jul Aug.. '72. Beth Israel Hospital - Jul. '68, p.2; July Aug -. '69, p.10; Sept. '69, p.13; Apr. '70, p.14; Oct. '70, p.3; Jul.- Aug. '72. Beverly Enterprises - Apr. '73, p.8. Biomedical Research - May '73. Group Health Insurance (NY) -Oct. '72. Group Practice -- Nov. '70, p.9; June '71, p.8. Gouveneur Hospital - Jul. '68, p.2; Jul Aug. -. '69, p.10; Nov. '69, p.10; Feb. '70, p.8. Birth Control - Apr. '72. H 1 Birth Control Pills - Mar. '70, p.10; Apr. '72. Black Lung Disease - Sept. '71. Blue Cross Jul. - Aug. '69, p.11; Sept. '69; Oct. '69, p.10; Mar. '71, p.1; Jul Aug. -. '72; Oct. '72, pp.19- 20, 23. Boston City Hospital - Jul - Aug. '70, p.15; Oct. '73. Boston University Medical Center - Oct. '73. Brian, Earl Apr. '73, p.16. Brindle, James - Oct. '72, p.17. Buffalo Medical School - Nov. '71. Bureau of Occupational Safety and Health -- Sept. '72. Byssinosis Sept. '72, pp.20-23. Haight Ashbury - Free Clinic - Oct. '71; Feb. '72. Harlem Hospital - Jul. '68, p.4; Nov. - Dec. '68, p.9; June '69, p.12; Dec. '70, p.6. Harlem Medical School Proposal - Oct. '72, pp.7-9. Harrington, Donald - Feb. '73, p.4. Harvard Medical School - Jan. '71, p.2. HEW Mar. '71, p.10; May '73. Health and Hospitals Corporation - Winter '69, pp.1-4; June '69, p.12; Sept. '69, p.7: Nov. '69, p.10; Jan. '71, p.9; Dec. '71; Feb. '72; May '72. Health and Hospitals Planning Council - June '68; Winter '69; Jul Aug. -. '69: Sept. '69, p.4; Apr. '71, C p.5; May '72, p.5; May '73. California Public Hospitals Apr. '73. Carnegie Foundation - Nov. '71. Case Western Reserve Med. School -- Jan. '70, p.12; Sept. '71. Center for the Prevention of Violence - Sept. '73. Certified Hospital Admission Program - Feb. '73, p.7. Cherkasky, Dr. Martin - Apr. '69. Chicago Health Movement - Apr. '71, p.6. Children's Hospital, Boston - Mar. '72. Chinese Health System - Dec. '72. Cincinnati People's Health Movement - Sept. '71. City University of NY Proposal (Med. School) -Oct. '72, pp.11-13. Citywide Save Homes - Our - Committee (NY) -May '72, pp.4-7. Health Inc., Boston - Mar. '72. Health Insurance Plan of Greater NY Oct --. '72, pp.15-22; Dec. '72. Health Maintenance Organizations (HMO's) -Nov. '70; Apr. 71, p.1; Dec. '71; Jul Aug -. '72; Oct. '72, pp 15-22. (HIP); Feb. '73 (Foundations); Nov. '73 (Kaiser). Health Planning (see Health and Hosp. Planning Council June - '68; Winter '69; Jul Aug. -. '69; Apr. '71, p.5; May '72, p.5. Health Professions Educational Assistance - Nov. '71; May '73, p.10. Health Revolutionary Unity Movement (HRUM) -Feb. '70, p.9; Jul Aug. -. '70, p.12; Sept. '70, p.13; Oct. '70, p.1: Dec. '70, p.9; June '71, p.10; Jan. '72; Jul Aug. -. '72. Cleveland Health System Sept. '71. Coler Hospital - Oct. '69, p.2. Columbia Medical Center Jul. '68; Aug. '68; Nov.- Dec. '68; Jul Aug. -. '69, p.10; Sept. '69. p.ll; Dec. '69; Feb. '70; Oct. '70, p.9: Dec. '70, p.6; Mar. '71, p.9. Columbia Hospital - Nov. '71. Columbus Hospital (Nov NY) --. '71, pp.10-12; May '72, p.6; Oct. '72, p. 24. Committee of Interns and Residents-- Aug. '68; Sept. '69, p.15. Community Control - Oct. '68; Nov. - Dec. '69, pp.1.5; Jan. '72; June '72. Health Services Administration - Jul. '68, p.1; Sept. '68, p.1; Sept. '69, p.8; Nov. '69, p.11; Jan. '70, p.10; May '72; Sept. '73 (Prisons). Burton Hill - May '72, p.1; Jul Aug. -. '72; May '73, p.8. Hilton Davis Co. (strike) -Sept. '71, p.5. Hospital Costs -- Jan. '70, p.7; Nov. '70, p.4; June '71; May '72, p.3: Jul Aug. -. '72. Hospital Expansion - Nov. '71; Mar. '72; May '72. Hospital Worker Unions - Jul. - Aug. '70; Sept. '70, p.16; June '71, p.6; Sept. '71; Oct. '72, pp.9,23; Nov. '72, p.6. I Community Medical School Proposal (Lincoln) -Oct. '72, pp.10-11. Community Mental Health - Aug. '68, p.4; Apr. '69, p.13; May '69 (Lincoln); Dec. '69. Community Mental Health Board (Dept. of Mental Health) May -- '69: Dec. '69. Industrial Health Foundation - Sept. '72. Industrial Medical Association -- Sept. '72. Institutional Licensure - Nov. '72, pp. 7-8. Insurance Companies - Nov. '69, p.6; Jul Aug. -. '72. Irvington House - Mar. '71, p.4. I Wor Kuen - Oct. '70, p.4. Community Mental Health Centers - May '73. p.9. Coney Island Hospital- May '72, p.8. Consultants -- Oct. '70, p.11. J Johns Manville Corp. - Mar. '73. Cook County Hospital- Apr. 73, p.7. Joint Committee on Accreditation of Hospitals (JCAH) Cornell / New York Hospital -- Sept. '69, p.11. D - Feb. '72; Apr. '73. Judson Mobile Unit Nov -. '69, p.ll. K Davis Medical School (Univ. of Calif.) - Apr. '73, pp. 10.11. Delafield Hospital -- Nov. - Dec. '68, p.8; May '72, p.8. Kaiser Permanente - Nov. '70, p.12; Nov. '73. Key, Dr. Marcus - Sept. '72, p.13. Downstate Medical Center - Sept. '69, p.13; Oct. '70, King General Hospital - Apr. '73, p.6. p.8. Knickerbocker Hospital - Nov. - Dec. '68, p.8; Oct. '72, E pp.7-9. L Einstein Montefio-r Aep r-. '69; Sept. '69, p.9; Sept. '70, p.12; Oct. '70 p.l; Jan. '71, p.6; Nov. '71; May '73 Lead Poisoning - Sept. '68, p.2; Apr. '70, p.13; Jan. (Einstein); Sept. '73 (Montefiore - Prisons). Ellwood, Dr. Paul -- Jul - Aug. '72. '71, p.8. Licensure Nov. '72, pp. 3-9. F Lincoln Hospital - Apr. '69; Sept. '70, p.12; Oct. '70, p.l: Dec. '70, p.9; Jan. '71, p.6; Jan. '72; Jul Aug. -. Federal Health Policy - Nov. '70; Apr. '71, p.1; May 172. '73. Lincoln Community Mental Health Center - May '69; Federation of Jewish Philanthropies - Apr. '69, p.9. Sept. '69, p.10. 19 Logan, Dr. Arthur - Oct. 72, pp.7-9. Lower East Side Neighborhood Health Council- South (LESNHCS) -Jul. '68: Jul Aug. -. '69; Sept. Physician's Assistants - Nov. " 72, pp.10-16. Piel Commission Report - June '68, p.4; Winter '69. p.7. '69, p.14; Feb. '70, p.8: Apr. '70, p.14; Jul Aug. -. '70, p.12; Oct. '70, p.4. M Planners Jul. - Aug. '68, p.8. Prepaid Health Plans (-Feb PHP's) . '73, p.14, Apr. '73, p.18. Madera County Hospital - Apr '73, p.6. Maimonides Community Mental Health Center - May '68, p.8. Martin Luther King Health Center - Oct. '69, p.3. Maternal and Child Care - May '73, p.10. Maximum Liability Health Insurance -- May '73, p.17. Prisons -- May '70; Nov. '71; Sept. '73. Professional Standards Review Organizations (PSRO's) -Feb. '73, p.12. Psychiatry - May '69, p.12; May '70. Public Health Hospitals - Mar. '71, p.8. Q Medicaid Winter '69; June '69; Sept. '69, p.6: Jul.- Aug. '72; Oct. '72, p.16; Feb. '73, p.10 (Medi - Cal); Apr. 73 (Medi - Cal); May '73. Queens Medical School Proposal - Oct. 72, pp.6-7. R Medicaid Mills - Jul. - Aug. '72. Medical Empires - Nov. - Dec. '68; Apr. '69; Sept. '69, p.9; Oct. 70; Apr. '73 (Calif.). Regional Medical Programs - Jul. - Aug. '69, pp.1.3; May '73, p.9. Research Guide - Feb. '71. Medical Industrial Complex - Nov. '69. Medical Imperialism - Apr. '70, p.8. Medical School Income -Nov. '71, p.5. Medical School Proposals (NYC) -Oct. 72. Medicare June '69, p.8; Nov. '69, p.7; Jul Aug. -. '72; S Sacramento County Hospital - Apr. '73, p.9. Sacramento Foundation for Medical Care - Feb. '73, p.7. May '73. Sacramento Medical Center - Apr. '73, pp.10-11. MEGA - May '73, p.14. Mental Retardation - Jan. '73. San Francisco General Hospital - Jul. - Aug. '70, p.17; Mar. 71, p.7: Feb. '72; Feb. '73, p.15; Apr. '73, pp. Merced County Hospital - Apr. '73, p.8. 20-24; Sept. '73 (Prison ward). Methadone June '70, pp.9.15. Methodist Hospital - Apr. 172. Metropolitan Hospital - Feb. '70. San Joaquin Foundation for Medical Care Feb. '73, p.4. Seaview Hospital - May '72, p.11. Michelson, William - Oct. '72, pp.19-21. Selikoff, Dr. Irving - Sept. '72, p.14: Mar. '73, p.3. Military Medicine - Apr. '70; June '71, p.4. Morrisania Hospital - Apr. '69; May '72, p.8. Mt. Sinai Medical Center -- Oct. '70, p.7. Shell Chemical Co. (No Pest Strip) -Sept. '71, p.5. Siskiyou County Hospital - Apr. '73, p.9. Smith, David - Oct. '71; Feb. '72. Moore, Dr. Cyril - Oct. 72, p.11. Social Workers - Sept. '70, p.11. MOTF (Mayor's Organizational Task Force on CHP) Soundview - Throgs Neck Tremont - Comm. Mental Health -Apr. '71, p.5. Center - May '69, p.8. Municipal Hospital System (Cutbacks: NYC -Win-) Stahl, Dr. William - Oct. '72. pp.11-13. ter '69; June '69. Staten Island - Mar. '71, p.8. N Sterling Drug Co. Sept -. '71, p.5. ; Student AMA - Mar. '70, p.14; Sept. '70, p.2. National Free Clinic Council - Oct. '71; Feb. '72. Student Health Organization (SHO -Aug) . '68, p.3; : National Medical Enterprises - Apr. '73, p.8. Mar. '70, p.14; Sept. '70, p.4. National Institute for Occupational Safety and Health St. Joseph's Mercy Hospital (Ann Arbor) -Oct. '72, - Sept. '72; Mar. '73. p.14. National Safety Council - Sept. '72. St. Vincent's Hospital - Jan. '70, p.12; Mar. " 71, p.6; Narcotics June '70; Dec. '70, pp.6,9; Jan. '72, pp.8.9. Jul Aug.. '72. National Health Corps -Apr. '70, p.9. Sydenham Hospital - Nov. - Dec. '68, p.8. National Health Insurance - June '69, p.7; Jan. '70; May '73, p.19. T National Institutes of Health (-May NIH) '73, p.11. Neighborhood Health Center - June '72; May '73, p.10. NENA (Northeast Neighborhood Assn.) - Jul. '68, p.1; Aug. '68, p.13; Oct. '70, p.4; June '72. New York City Prisons Sept. 173. New York Infirmary - June '72, p.4. New York Medical College -- May '69, p.9 (Commun- ity Mental Health Ctr.); Sept. '69, p.12; Oct. '70, p.6. New York Times Feb. '70, p.ll; May '70, p.13. New York University Medical Center- Sept. '69, p.13; Apr. 70, p.7 (Bennett); Oct. '70, p.3; Mar. 71 ", p.4; Taxes - June '71. Therapeutic Communities - June '70, pp.9.15. Think LincolnSe p-t . '70, p.13; Oct. '70, p.1; Jan. '71, p.6. Thursday Noon Committee Feb. '72; Apr. 173. Tunnel Workers - Oct. '70, p.10. Trussell. Dr. Ray Nov. - - Dec. '68, p.10; Apr. '70, p.14; Jul Aug.. '72. U UCLA Medical Center - Jul - Aug. '70, p.16; Sept. " 73. June 72, p.4; Sept. '73 (Prison ward); Oct. '73. Nixon, Richard Nov. '70; Apr. 71, p.1; May '73. North Central Bronx Hospital -- May '72, p.8. United Harlem Drug Fighters - Oct. '70, p.ll; Dec. '70, p.6. V Nursing Mar. '70; Sept. '71, p.1: Apr. '72; Sept. '72 (letter); Nov. '72, p.16. Nursing Homes - Nov. '69, p.7. oO Valley Medical Center - Apr. '73, p.6. Vanderbilt Clinic - May '70, p.7. Veterans Administration Hospitals - Apr. '70, p.5; May '71, p.9. Occupational Health - Feb. '70, p.5 (GE); May '71, p.6; Sept. 71, p.5: Sept. '72; Mar. '73. Occupational Safety and Health Act Sept -. '72, pp. Vietnam May '71; Oct. '72, p.24. Voluntary Hospitals - Oct. '69, p.9 (Cutbacks). W 15-19. Occupational Safety and Health AdministrationL Sept. '72. Office of Management and Budget (OMB) -- May '73, p. 15. Oil, Chemical and Atomic Workers Union - Oct. 72, p.23. P Walsh - Healy Act Sept -. 72, p.15. Washington Heights - Inwood Community Mental Health Center Nov. - Dec. '68, p.9; Apr. '69, p.10; Dec. '69. Weinberger, Caspar - May '73, p.15. Wesley Hospital (Chicago) -Jul - Aug. '70, p.16. Willowbrook State School - Jan. '73. Women's Health - Mar. '70; Apr. '72; Dec. '72. Patients'Rights - Oct. '69. Peace Movement - May '71, p.6. Pediatric Collective - Oct. '70; Jan. '71, p.6; Jan. '72. Peer Review - Feb. '73, p.5. Y Yolo General Hospital - Apr. '73, p.6. Young Lords - Oct. '69, p.4; Feb. '70, p.9; Sept. '70, p.13; Oct. '70, p.1; Dec. '70, p.9; Jan. '72. 20