Kaiser offers use of outside doctors


May 03, 1994|By Patricia Meisol | Patricia Meisol,Sun Staff Writer

Expect the unexpected. That's the word from the health care reform front. Kaiser Permanente, the country's first health maintenance organization, is offering members the opportunity to be treated outside its HMO for the first time.

The reason: as employers switch to managed care, they want to preserve their employees' ability to choose doctors.

As a result, the biggest growth in managed care in the past four years in the Baltimore-Washington market has come not in HMOs but in so-called individual practice associations, in which managed-care companies sign up hundreds of doctors who agree to accept their fees and offer members the right to choose from among them. The new Kaiser option, called a point-of-service program, allows customers to see an outside doctor for an extra fee.

Until now, members in the Kaiser system have been treated by a set group of doctors, company-owned clinics and hospitals. Kaiser was the first company to both offer health insurance and provide a complete line of health care, and today the company is a model for such "integrated" health systems. It has gained members in recent years and remains the country's largest private health care system, with 6.6 million members.

But as others move in, including doctors and hospitals that are trying to build integrated systems of their own, Kaiser is wondering how much to change and in which direction.

"At a time when the market is moving in our direction, we are not sure how much to move in the other direction," said Alan J. Silverstone, senior vice president of Kaiser's mid-Atlantic region, which covers 320,770 people.

Mr. Silverstone told a recent gathering of health care executives that he is not convinced that choice will result in better or less costly care, or that the individual practice associations model will last. Nor is he convinced, from Kaiser's experience, that hospitals and doctors and other medical providers will find it easy to enter into networks that contract on behalf of all of them and take risks once held only by insurance companies.

"Can physicians get along with each other and with hospitals?" he asks. Once people put their money down, can the players agree on how it should be divided? How will

the new system get capital to pay for information systems and to ride the bad years any insurance company must be prepared for?

Kaiser was the first to charge a preset fee for each member, in exchange for which it agreed to provide complete health care.

The HMO was founded in 1938 by Henry J. Kaiser to serve workers in isolated parts of California where he built his steel and aluminum industries. When Kaiser opened the plan to the public in 1945, it was considered so radical (Communist, actually) that doctors couldn't get privileges at local hospitals. So Kaiser built its own hospitals, creating a complete system of care for its workers.

Most of its company-owned hospitals are on the West Coast. In the mid-Atlantic region, which it entered only in 1980, Kaiser has its own clinics but contracts with local hospitals that credential its physicians. The hospitals include Holy Cross in Silver Spring and the Greater Baltimore Medical Center in Towson.

As the plan grows, Mr. Silverstone says, Kaiser is looking at partnerships with other local providers to expand its line of health care. Reform, in the end, is a moving target.

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