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Chapter 6 RAISER-PERMANE~TE MEDICAL CARE PROGRAM OF OREGON The Kaiser-Permanente Medical Care Programe in Portland, Oregon, a prepaid group practice and federally c~ualif fed health maintenance organization. The practice began in the early 1940s and currently serves a community of enrollees number ing approximately 26S, 000. lathe Kaiser/Oregon program includes a health services research center estab- lished in 1964 specif ically to study the potential of a prepaid group practice as an important innovation in the organization of health care. The innovative programs developed make Xaiser/Oregon a particular ly good case study for demonstrating the manner in which an TO can embody the ma jar pr inciples of COPC by addressing the health needs of its enrolled population. Me history of Kaiser/Oregon has become a legend in the development of innovative medical care delivery systems (Kaiser Permanente, 1983~. In 1938, Sidney Garf ield, M.D. had recently developed a successful pre- paid medical program for the workers constructing an aqueduct to carry Colorado river water to Los Angeles, and agreed to replicate that pro- gram for the Kaiser/Oregon organization during its building of the Grand Coulee Dam in eastern Washington. Following completion of the dam, World War II broke out and the Raiser/ Oregon organization in con junction with Dr. Garf idle developed prepaid plans for the employees of the Kaiser/Oregon shipyards and steel mills along the west coast of the United States. The Port land progr am evolved f ram the or ig inal program. to se roe the employees of the Xaiser/Oregon shipyard in Vancouver, Washington. Following the end of World War II, the plan membership dropped preci- pitately and over the next several years the program operated on a minimal budget. While overcoming virtual ostracization by the medical establishment and working through the development of a functional and stable management philosophy, the program survived into the 1950s. Early in the development of Kaiser/Oregon, as was true for all the Kaiser/Oregon regions, there evolved a nonprof it management structure and an independent professional association made up of the physicians. *Hereafter referred to as Raiser/Oregon 93

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94 In the 1950s, the membership of the Kaiser/Oregon program remained relatively constant at about 25,000 members. In 1959, the program moved its base of operations from Vancouver to Portland, and opened ~ new hospital that stimulated a rapid growth in membership, climbing to approximately 75, 000 by the mid-1960s. An early medical director of the Kaiser/Oregon program, Ernest Saward, M.D., believed that the development of the prepaid health maintenance organization represented a substantial experiment in the organization of medical care. He believed that the organization had an obligation to make itself available as a laboratory for the study of this innovative approach to the delivery of health services. In 1964, Dr. Saward established the Health Services Research Center within the Kaiser/Oregon organization and enlisted Merwyn R. Greenlick, Ph.D., to be its director. Since that time, the Kaiser/Oregon- medical program has many p ioneer ing accomplishments to its credit . In the late 1960s, the Kaiser/Oregon program was awarded one of the org inal OE'O demonstration grants and proved to be successful in prom viding comprehensive medical services to low income families within the Portland area. In the mid-1970s, the Kaiser/Oregon program demonstrated that the prepaid format could accommodate expanded services for a Medi- care eligible population. Currently, the Kaiser/Oregon program is experimenting with a greatly expanded benef it package for Medicare eligible patients, including a variety of health and social services not previously offered within a prepaid medical plan. Kaiser/Oregon's success as a co~nmunity-oriented primary care pro- gram can be attributed to a number of factors not the least of which is the foresight on the part of a number of individuals in key positions in the organization. There was an organizational willingness and capa- bility, because of size and financial viability, to experiment with the organization of medical care. In addition, and perhaps most important in terms of COPC, is the commitment {based on both economic and social incentives ~ to look at the total population of health plan members when planning services. According to Dr. Greenlick, director of Kaiser/Oregon' s Health Services Research Center, there is a Management cultures that promotes a strong sense of accountability to and respon- 5ibilitV for the community of plan meters. THE PRIMARY CAME PROGRAM Organization of Program As one of nine regions, the Oregon Region of the Kaiser-Permanente Medical Care Plan is part of the largest health ma intenance organization in the United States. Raiser/Oregon is a federally qualif fed HMO and complies with standards related to governance, range of benef its, and mechanim,,s to assure quality of care. The principles that characterize the Kaiser-Permanente system of medical care organization are voluntary enrollment, prepayment for services, comprehensive benefits, preventive medical care, integrated hospital-based health care facilities, and provision of ohvaician services through group medical practice.

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95 Organizationally, the Oregon Region consists of three entitles, the Raiser Foundation Health Plan, the Kaiser Foundation Hospitals, and the Northwest Permanente Professional Corporation. The f irst two are part of the Raiser Health Plan and Hospital Organize ion and as such relate organizationally to the central off ice management in Oakland, California. The Northwest Per~nente Professional Corporation is an independent group consisting of approximately 295 salar fed physicians who provide all physician and paramedical professional services for the Raiser Health Plan in Portland. me physician group in turn is loosely subdivided into two areas, the Sunnyside and the Bess Kaiser areas and each has an area medical director who reports to the president of the professional organization. A dental program is an integral part of the Xaiser/Oregon program and the dental group is organized into a separate professional corporation. Within Kaiser/Oregon, there are two organizational entities that have an important impact on the organization well beyond that suggested by their location on the organizational chart. The Health Services Resee rch Cente r (HSRC) was den igned spec if ically to study the ~soc ial eager iment. of which the development of health maintenance organization represented. The stated goals of the MSRC are to study: the impact of providing new health care Services to an existing, identif iable population in an established medical care system the impact of providing services to populations new to a medical care system the impact of implementing new methods and new personnel for the provision of exist ing services in a medical care system the theoretical conceptual issues of medical care utilization resee rch . Intended to function s~isutona~nously within the Oregon program, the Health Services Research Center nonetheless has had a profound effect on the direction and operations of the health program. Many of the innovative approaches to extending the benef its of the health services are directly attributable to studies originated at the Center. Although HSP~ exists within the organizational structure of the Kaiser-Permanente Medical Care Program, only about one-third of its funding comes from the organization and the rest is from outside sources. More recently, the Department of Community Medicine has been estab~ fished with David Lawrence, M. D., as its chairman. Or . Lawrence is a vice president of the Northwest Permanente P.C. and serves as Area Director of the aesS Kaiser Area. Members of this department are drawn strategically fran the medical group as well as frown the Health Plan and Kaiser Hospital Corporation. The major impetus for developing the department came in response to the recogni tion that much of the

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96 morbidity and mortal ity of the Ra iser/Oregon populat ion was related to behavioral variables. This recognition combined with a number of envi- ror~ental inf luences led the organization to an effort to address those com~unlty factors that impinge on the health of the Kaiser/Oregon com- munity. Anne Department of Community Medicine is currently engaged in a var iety of health promotion activities for its general membership. It is also shar ing i ts expertise with nonmembers through a number of pro- grams it conducts at work sites, and for the general public through a television program called replanning for Health. Staf f and Facilities Facilities of the Sunnyside Area health program consist of Sunnyside Hospital (currently lS0 beds, with a capacity ultimately of 2S0 bean) and three medical offices in addition deco a medical office south of Portland in the town of Salem. The Bess Raiser ares operates a 200-bed input lent service (total capacity is 212 beds) and f ive medical of f ices, the northernmost eight miles north of downtown Portland in the town of Vancouver, Washington. Although patients may elect to see a single physician for all of their visits, patients are free to seek health care at any Kai~er/Oregon facility within the Oregon region and consequently may receive care on subsequent visits from several dif fer- ent physicians. Currently, the physicians at the Vancouver Medical Office are experimenting with a plan in which the practice is divided into several teams or modules, and further into individual physician panels. Each plan member will select a team and a physician for all of their pr imary care . Serving the patients of both areas is an extensive have health program that provides both home health services and homemaker ser- vices. Home health program staff includes a director, two nursing supe rvisor ~ and 3 4 f till-time equivalent provide r s cons ist ing of reg iste red nut ses, physical therapists, occupational therapists, and social workers. This program provides over 2,000 home visits and approximately 113 homemakers visits per month. As recently as three year. ago, the consumers of the home health program were nearly exclusively Medicare patients, but with the recent decrease in the scope of several community agencies there has been a rather dramatic increase in the utilization of the home health services for maternal and child related services. Although the Raiser/Oregon program does not operate a nursing hale facility, their benef it plans provide skilled nursing, and acute care. Medical Records In order to promote continuity and coordination of care at Kaiser/Oregon, a single record containing all data from hospital- izations, outpatient visits, and outreach services is maintained in a central facility. The records are delivered on a daily basis to those medical off ices in which patients have a scheduled appointment. The

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97 disadvantage of this system is that patient. making unscheduled appointments are seen by a provider without the benef it of their complete medical record. The medical records are not computer Sized although there are plans to develop a cl inical data system in the near f uture . Da Inca Sys tems one health care program in supported primarily by three data systems: an accounting system, a member information system, and a clinically rich research data base system maintained by the Health Services Research Center (HSRC) on a f ive percent sample of members (Kaiser/por~cland, n.d. ~ . The medical records of the nearly 250,000 members of the health plan are not computer ized, nor is there any substantial computer support for the medical record within either of the two medical centers of the Oregon region. me member information system is maintained by the Medical Economics Department, and supports a var iety of activities that serve to monitor the characteristics of the enrolled community. me file of enrollees is kept up to date and can at any time produce a listing of the entire community . The research data system has been maintained since 1966 on a randomly selected f ive percent of -embers in addition to all or an augmented sample of members enrolled in special programs such as the orginal OEO neighborhood health center program and the more recent Medicare Plus. Although not including the entire enrolled community, this data base has been carefully developed to ref lect the patterns of health and utilization of the general population of members. In addi- tion to its many applications to the varied research activities of the MSRC, the data base has been employed to generate data on the community, its health problems, its patterns of utilization of services, and on the effectiveness of intervention programs. Its only drawback (in comparison to data support systems in other study sites) is its ine- bility to generate and maintain cw=.unity-wide listings of specific patients, i.e., as in disease-specific registers, tickler files, etc. However, a tumor registry and a computer f ile of pathology reports coded by diagnosis have been maintained for well over ten years by the pathologists and oncologists of Raiser/Oregon. Organization of Financing AS a health maintenance organization, Raiser/Oregon has f inancing markedly different from other practices and programs visited. People who choose Ka] ser/Oregon as their health care provider enroll with the health plan as a member . As specif fed in a contractual agreement, the service. the member receives are prepaid. Kaiser/Oregon as the provider group directs, provides, and/or arranges for all covered medical ser- vices including inpatient, outpatient, and ancillary services. Once enrolled, the medical care of the memt~ers becomes the responsibility Of

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98 the Northwest Permanente Professional Corporation, a group practice of physicians who represent most ma jar medical and surg ical specialties. Because of this particular relations ip between provider and enrollee, most of the revenues for operating thin program are generated f rom member dues rather than from third-party payers as is more typical in fee-for-service, private practice. Aproximately three-f ourths of the revenues to operate the Raiser/ Oregon Health Plan are provided by member dues (Table 6.1~. These dues, for the most part, are paid jointly by the members and the members' employers. The dues usually come frost payroll deductions with direct payments to the Raiser/Oregon Health Plan. The ocher 25 percent of the revenues comes f ram a combination of: . supplemental revenues of 6-9 percent that include payments by plan member s outs ~ ret either as deductible or as a form of coinsurance when their particular benef it plan does not pay the entire amount of the service, and payment by liable thi Ed parties Medicare parts A and B (11-13 percent) with what Raiser/Oregon has a special f inancial arrangement for providing medical care to Medicare beneficiaries who are Faiser/Oregon enrollees nonplan and industrial funds (5-6 percent); i.e., for members who are injured or become ill at the work site as well as some private patients and some industrial care that is provided to norenanber ~ a general miscellaneous category of funding (less than 1 percent). As can be seen in Table 6.1, the percent dis~cribution of sources of revenues has remained relatively stable over the past f ive years. With a source of f inancing largely derived from capitation there are economic incent ives to keep the def ined Community ~ or population well. Anticipating health problems, identifying health needs, and responding to those needs would seem particularly useful unbar a capitated system. Having revenues associated with people rather than services allows for a good deal of f lexibility in the way care is organized. Theoretically, it encourages the provider {or health plan in this case) to assume responsibility for the entire membership; it can serve to f ree h un or her to engage in COPC-type activities that tend to be discouraged, at least from an economic standpoint, in a fee- for-service envi ronment . HSRC receives a portion {23. 7 percent in FY 82) of its funding from the Kaiser Foundation Hospital' ~ Community Services Program. However, the major portion of its funding {76. 3 percent in FY 82) comes from outside sources (Table 6. 2) . Marring a unit like HSRC within Raiser/ Oregon and capable of generating revenues primarily for researach and development gives Kaiser/Oregon an edge over its competitors and it.

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99 TABS 6.1 Percent of Total Annual Revenues for Raiser/Oregon' 8 Medical Progr am by Source and Year 1982 1981 1980 1979 1978 OCTAL REVENUE ( I N THOUSANDS ) 1 FOR PERSONAI' H"LTH SERVICES2 . 3153,112 100% Prepaid Members Dues ~ includes Medica id capi tation) Supplemental (Out~of- Pocket f ran Members) S127, 015 3106, 833 390, 804 S78, 290 100% 1001 1001 1001 781 771 72t 73t 731 61 7t 8% 8% 91 Medicare (A & B ~ 111 111 13% 131 118 Non-plan Industr ial 51 51 6. 61 61 All other 0. 4% 11 1% 1% 21 These revenues are generated by the Health Services Research Center f rom sources outside Xaiser/Oregon. 2 Includes revenues for both inpatient and outpatient services. counterparts in the fee-for-ser~rice world when it comes to COPC func- tions def ining its population on a number of dimensions, identifying the health needs of that population, and monitor ing the of feats of changes in the program. She extent to which Kaiser/Oregon has taken advantage of this edge in still somewhat unclear. THE COMMUNITY Demography Ra iser/Oregon def ines the community for which it is responsible as the aggregate of its me~t~ership, those people with whom they have a contractual relationship to provide health care. By virtue of the contractual relationship, Kaiser/Oregon has a def ined population and the individual members at any point in tinge can be enumerated. Raiser/Oregon has as its community approximately 20 percent of the population of Greater Portland.. Half of the work force of Greater

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100 TABLE 6.2 Percent of Total Revenues for the Health Services Research Center at Raiser/Oregon by Source and Year FY 1982 FY 1981 FY 1980 FY 1979 TOTAL REVENUES E OR HEAl`TH SER`rICES RESEARCH CENTER Ka ise r Foundat ion Hospital (Community Se rvice Program) S2.864,117 S2,952,541 S2,938,163 32,345,469 100% 100. 1001 100% 23.1% 22.1% 21.41 24. 6% Outside Servicers 76. 3. 77. 9% 78. 6% 7S. 4% Greater than 90 percent of outride revenues are f tom federal sources; the remainder is from private sources. There were no state or local funding sources at the time these data were compiled. Portland in elig ible to enroll, and approximately 40 percent of the people with an option to enroll actually do so. The demographic char- acteristics of the membership are almost identical to the Portland area, a continuing trend that is conf i rmed by surreys conducted annually by the Medical Economics Department and by the Health Services Research Center every three years. Despite the propensity for HMOs to nerve a predominantly employed population, the various Medicare and Medicaid arrangements developed at Raiser/Oregon balance its membership to con- sistently reflect the socioeconomic characteristics of the Portland ares, including age, sex, health status, and employment status. Community Involvement With the lCat~er/Oregon program there are no formal mechanisms for community participation and there are no community boards as such. Mere are, however, several ways to capture the input of individual members. First, there is a procedure by which a health plan member may egress d issatisf action, with the guarantee of a wr itten response within 30 days. Annual member surveys are conducted by the ESRC focusing on the member's perceptions of quality and availability of services. A survey of individuals who terminate their membership in the plan has been reinstituted. Also there is the Realth Care Advisory

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101 Council that was originally set up to represent members, but has evolved into a group that represents benefits managers from various employer groups. This is a very different constituency but, nonetheless, one to which Kaiser/OregOn Oust be responsive. Another source of input from the general community of Portland comes in the form of special requests from various community agencies. The Kaiser/Oregon Program has high visibility as a health maintenance organization in the Portland area and consequently is called upon f requently to conduct programs and participate in community health care events. These requests and the subsequent activities of ten br ing Raise r/Oregon into new settings the Portland area and of ten help to identify health needs of the broader community. The form of community participation in the Kaiser/Oregon program differs fran that of many of the other study sites. However, in the late 1960s Kaiser/Oregon received a grant from the Office of Economic Opportunity and developed a health plan for a medically underserved population in Portland. As a part of this program, an active community board f unctioned for a number of years. COPC ACTIVITIES AT RAISER/OREGON AS an organization, Kaiser/Oregon is concerned about maintaining a volume of enrollees that permit it to operate eff intently. In this regard the organization participates in rather vigorous efforts at developing and marketing its various plans within the greater Portland area. While many of the marketing efforts are directed toward qaner- ating an enrolled population, per se, the program also has a history of developing and marketing plans that are tailored to meet the health needs of components of the community that are either underserved or for wham Kaiser/Oregon feels it could provide more comprehensive Services. Once enrolled, the Kaiser/Oregon program has dealt aggressively with the new subset of its community in attempting to identify the major health problems and to develop and evaluate innovative strateg ies for meeting the needs for health services. In general, marketing one' ~ program within a larger community is not a component activity of COPC, although it is recognized that all programs and practices must engage in some marketing to assure economic survival. On the other hand, marketing activities that bring into one' s community a group of people in need of service with subsequent efforts to address their health needs is consistent with the COPC model. Among the activity summaries that are presented below, the f irst two are examples of the combination of developing a health plan for a relatively underse rved population, marketing that plan to bring new people into the enrolled community, and addressing their specif ic health needs.

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102 Prevent ive Se rvices for Ch lid ren In the mid-1960s a large number of families lived in the Portland area who did not have financial access to adequate health care. With a small grant from the Office of Economic Opportunity, the RSRC employed 2S outreach workers to do a door-to-door survey of the health needs and service utilization of 5 target areas of Portland. As a result of this survey, the target areas were determined to meet OEO's criteria for a demonstration project. The HSRC developed a prepaid program of compre- hensive care, including basic ambulatory, outreach , and inpatient care , to provide comprehensive health services to approximately 7, 000 indivi- duals in I, 500 families. Features of the plan for this population, not typical of the Kaiser/Oregon plan at that time was the provision of transportation and outreach activities as the full time responsibility of neighborhood health coordinators (Colombo et al., 1979; Creighton et al., 1910 ; Greenlick , 1971 ; Johnson and Azevedo, 1919) . Early in the course of the pro ject the community board identif fed child health as a def inite pr iority. Preliminary data on the health care utilization of this population, suggested considerable underutili- zation of services for well child supervision and preventive care. A previous study had demonstrated that the use of the outreach worker could result in signif leant and appropr late changes in utilization of services (Freeborn et al., 1978) . consequently, in order to improve the well child preventive care, the program devised an outreach protocol to contact and bring into preventive care the children of this subset of the community. The impact of this program was evaluated based on an experimental design that divided the families into two groups--one to receive the outreach visit and one without. After an appropriate period of time, indicators of primary preventive service, e.g., OPT, polio, rubella, and mumps immunization, Tine testing, etc., were computed for both groups. The results demonstrated that the children needing preventive care increased their utilization of services and higher proportion received the appropriate preventive and screening services (Colombo et al., 1976~. }Iealth Care for the Elderly Census data for the Portland area and Kaiser/Oregon' s own data reveal a growing elderly population. Over the past 10 years, the trend has been for employers to extend health benef its to pensioners, which has resulted in an increased number of retirees being included in the Kaiser/Oregon community. Recognizing that an aging population tends to need more health services than the under-65 population, Kaiser/Oregon has modif fed its program to accomodate these needs. In 1980, Kaiser/Oregon, with funding f ram the Health Care Financing Administration (HCFA), developed a workable prospective payment system known as Medicare Plus, which is attractive to Medicare beneficiaries because it offers them either a premium saving or an expanded benef its package . At ter Kaiser/Oregon instituted the Medicare PIUS Project, the

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103 percent of their enrolled community over the age of 6S years increased from 6.8 percent {1979) to 9. ~ percent (1981), and as a result their enrolled con - unity now includes 17 percent of all Medicare benef iciaries in the Portland standard metropolitan statistical area (SMSA}. HCFA is currently funding an independent evaluation of this project (Greenlick et al., 1983) . In addition to Medicare Plus, Kaiser/Oregon has proposed to HCFA that they be one of four demonstration projects experimenting with expanding services to 2,000 of Raiser's Medicare enrollees, 1,500 new members, and 500 elderly Medicaid beneficiaries. The program known as Medicare Plus lI proposes to offer social services (e.g., adult day care, homemaking, medical transportaton) and long-tern care (e.g ., 100 additional days of intermediate or skilled nursing care, increased home health care) in addition to the medical care already offered under Medicare with the goal of keeping benef iciaries out of long-term care. Medicare Plus II has been proposed but, to date, funding has not been awarded. No systematic evaluation of Medicare Plus II has been planned. A third program, Cage Net, ~ has also been proposed and is in the planning phase. Ape Net is a senior volunteer network, comprised of aged Kaiser/Oregon members, that would constitute a social support system for the elderly population. To date, no evaluation plans have been designed for the program. Sudden Inf ant Death Syndrome The pediatr ic stat f at Kaiser/Oregon, aware that Oregon has a higher rate of sudden infant death syndrome (SIDS) cases than the nation as a whole, and aware that Kaiser' s rate was comparable to the city of Portland, designed a program to try to reduce the number of SIDS cases in the Kaiser/Oregon community, which in 1980 and 1981 was 10 per year out of approximately 3, 840 births each year. In 1981, under the direction of Dr. Gunnar Waege, Director of Neonatalogy at Raiser, the staff began identifying high risk babies using criteria put together by Or . Waege and based on cur rent medical knowledge and the epidem iolog ic 1 i terature on SIDS . All babies in the enrolled community of Kaiser/Oregon under one year of age who meet the following criteria were identified as high risk: . newborns with birth weight under 1, S00 grams newborns over 3S-week~ gestational age with identif fed apneac episodes {i . e., 15 seconds or longer) while in the nursery all infants of multiple births when one of them has had identif fed apneac episode . babies under s ix months with observed apneac episode in home and brought to the attention of the emergency room stat f or Kaiser/Oregon's 24-hour Advice nurse. ~

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104 Once the higher isk identif ication is made, the monitor ing prog ram begins. Parents of high-risk children are instructed to rent a heart rate monitor since it is not a covered benef it. If parents are unable to afford it, Kaiser/Oregon assists them in obtaining one. The parents are then instructed by a home health nurse in the hospital to recognize the subtle signs of apnea, CPR for infants, adaptations needed in the home (e.g., warmer temperture), and how to keep records. A home health nurse then follows up thin instruction with a home visit within 48-72 hours after discharge and makes regular visits (from 2-3 tunes a week to once a month depending on family needs) to the home in order to reinforce the instructions and advise on care. The babies are generally on the monitor f ram three~months to one-year duration. After two years experience with monitoring these high-risk babies, Raiser 'a number of SIDS has dropp - ] from 10 per year in 1980 and 1981 to 4 per year in both 1982 and 1983. The total births at "iser/Oregon were approximately 3, 840 in 1982 and 3, 600 in 1983. According to Kaiser/Oregon staff, during that same time, the state' s rate has remained the same. Continued monitoring of the program is planned. The medical and nurs ing stat f involved in this program at Ka iser/Oregon do not suggest that the differences in mortality rates are statistically signif icant nor that a causal relationship between the monitoring and the reduced number of SIDS, has been demonstrated. However, the program does illustrate the process of identifying a health problem, targeting a subset of their population at risk, modifying services, and monitoring their effects. Other COPC A`:tivities Kaiser/Oregon appears to be organized to deal aggressively with issues in health promotion. The recent formation of the Community Medi- cine Department incorporates a number of foci of activity in industrial health, employee health, and health promotion. These ef forts are f i rmly based on a view of the entire community at risk as a denominator upon which all intervention ef forts are founded . The health promotion work takes place against a background of more than ten years of systematic study at the HSRC of such lifestyle change ef forts as the NIH-funded Multiple Risk Factor Intervention Tr ial for the prevention of coronary heart disease, and an even longer tradition of service to Ksiser/Oregon' ~ employees and to the larger community. By early 1982, this work had evolved into the HSEC Health Behavior Clinic, an ongoing laboratory for studying the costs and effects of innovative, comprehensive programs of health promotion and disease prevention. Health Services Research Center personnel were awarded the U. S. Secretary of Health and Human Services 1983 Award for Excellence in Community Health Promotion and Disease Prevention for the two~year-long Fight Against Fat. campaign conducted on a popular, locally broadcast morning television program, CAM. Northwest. (EATU-TV, Portland) . Mem- bers of the ARC professional stat f appeared monthly on the prog ram, as did s ix volunteers with whom they met weekly; 6, 000 sets of printed

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105 materials were mailed to viewers requesting them; and 35 percent of the target audience reported participation in the program. Within two years of the development of the Health Behavior Clinic ' a, Freedom from Fat. program, more than 1,000 people had enrolled in the program. me Health Behavior Clinic ' ~ Freedom f ram Cigarettes. pro- gram, initiated in 1983, enrolled about 100 people in its f irst year, and has received federal funding for continued development and research in the second year. Second year enrollment is expected to exceed 700 cookers. Both programs are open to the general public, and the initial funding for both came from user fees, either directly or through third- party payments; Kai~er/Oregon employees receive attendance-based partial reimbursement for their participation. Rapture marketing ef forts in health. promotion programs will be targeted largely on industry and the workplace for several reasons: . there is a growing awareness of def inite health problems related to the war kplace an effective set of interventions would lead to heal thier people twith the economic incentives of lower utilization of services) health promotion programs in the workplace would widen the exposure of Ralser/Oregon health promotion in the workplace is seen as a potential source of revenue largely untapped by the health care system. Although Kaiser/Oregon focuses on the community composed of its membership population, it nonetheless engages in multiple activities that benef it the broader community of metropolitan Portland. for example, Kaiser/Oregon is currently engaged in a fairly broad effort to develop health promotion activities in the work place. It responds to frequent request by employers to conduct seminars, to initiate health promotion activities in their workplace and to do f itnese assessments. Kaiser/Oregon now sponsors a television show called planning for Health,. which is a monthly, half-hour show with 20 airings over the course of one month. Raiser/Oregon also has become involved in a teenage alcoholism program work ing with the local school system. Data for the metro- politan area of Portland suggest that the prevalence of chemical dependency among adolescents is as high as 15 percent. Extrapolating to the approximately 35, 000 adolescents enrolled in the Kaiser/Oregon Plan, as many as 5, 2S0 adolescents might be abusing a drug or alcohol. Consequently, Raiser/Oregon is participating in the planning phases of a program directed at the school-age population for comprehensive pre- vention and set eening of adolescents with a drug/alcohol abuse problem. Finally, physicians in the Vancouver medical office participate with physicians from the local medical society in setting aside severs1 days in the fall and spring for sport physicals, and to provide obstetrical care of indigent pregnant women.

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106 ANALYS IS OF RAISER/OREGON AS A COPC ORGANI ZATION In order to put the many and varied activities of Raiser/Oregon into a COPC perspective, it is necessary to consider both the essential f Nature of Raiser/Oregon and the ways in which it views the community to which it addresses itself. Some of the features of Raiser/Oregon are a physician owned group practice, the integration of inpatient and outpatient care, prepayment on a capitated basis, and physician respon- sibility for cost and quality of care. In addition, Raiser/Oregon is bound by contract to each of its individual members to assure not only pr imary care, but also all needed servicer within the scope of the benef it plan. In this regard, their scope of responsibility is closer to that of the Sells Service Unit of the Indian Health Service than to any of the other study sites. In both organizations there is not only a professional but also a clear economic incentive to identify remediable health problems within their community. The Functions of COPC Def ining and Character izing the Community line Medical Economics Department routinely performs a number of studies that serve to maintain an accurate and current prof ile of the enrolled community. This department maintains and analyzes member util ization statistics and produces utilization projections which, in the short term, dr ire the development of the budget, and in the longer term drive facility planning. Market analyses examine the potential of entering new market. with forecast of the increase membership that might result. A major activity is the development and maintenance of the Member Relation Data Base that captures data f tom the routine member satisfaction survey, the survey of disenrolling meters, and the data collected on patient complaints. Finally, a major household survey was done in 1978 and in 1981 and is scheduled again for 1984. This involves surveying 1,000 households in the greater Portland area to determine the source of care, satisfaction, and attitudes about health services . In the aggregate the activities of the Medical Economics Department serve to characterize the community and produce a complete enumeration of the individuals constituting the enrolled community. This places the ICaiser/Oregon program at stage TV in the development of this COPC f unction. Identif ication of Community Health Needs To a far greater extent than any of the other study sites, the Xaiser/oregon program has formalized mechanisms for identifying the health needs of its enrolled community (Greenlick, 1974; Oleinick and Mul looly, n.d.; Vogt, 1979) . Organizationally, the majority of routine mechanisms are operated either out of the ESRC or the Medical Econc~nic. Department, however, a substantial continuing activity in

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107 assessing the health needs of the community can be found throughout the program. Recently, many of these activities have been incorporated into the Community Medicine Department. Kaiser/Oregon pays particular attention to issues of satisfaction with and availability of health service. (Pope, 1978; Freeborn and Pope, 1981~. Information is gathered through the annual membership survey and results are used to modify variables and program operation, especially those that interface with patients, such as modifications in regular office hours. Satisfaction of the members with the health care received is apparently taken seriously and one management principal was quoted as emphasizing patient satisfaction is an operating statistic. ~ In general, the Raiser/Oregon program operates at a very high level of development of this function of COPC. Although the systematic and routine nature of the function is not well represented in the problem specific examples of COPC activities, Kaiser/Oregon has in place a number of routine mechanisms that serve to identify and describe the health needs within the community. Certainly, the examples cited in address ing the health problems of the medically underserved and the Medicare eligible population demonstrate a clear attainment of stage IV in the developmen~c of this function. The identif ication of sudden infant death syndrome was based on cononunity-specif ic data and is character istic of stage II I . Edifying the Health Care Program Modif ications of the pr imary care program generally take the form of changes either in the structure and process of operations or in the form of changes in the conf iguration of benef its within the various plan. offered to subscribers. Often the modifications made in the benef its plans incorporate e lements of ten thought of as community health activities, such as the outreach activities involved in the home health program (Hurtado et al., 1972), alcohol treatment service (Colombo, 1976 Noel and Colombo, 1978), dental care (Oleinick and Mullooly, n.d.), and the variety of services offered in the Medicare Plus effort and those planned for the Social HMO. The variety of activities and the systematic attention directed at developing benef it plans to meet the needs and demands for service of the community, place the Kaiser/Oregon program at stage II I for the development of this function. The effort to address the problem of sudden infant death syndrome (SIDS}, however, made provisions for targeting services on a group of specific infants at risk, and in an example of stage IN development for this f unct ion . Modifications in the conf iguration of benefits often are driven by forces independent of the COPC process. Many occur simply because ser- ~rices became a part of the community standard . for example, although Kaiser/Oregon recently turned down its first request for a heart transplant, it is anticipated that eventually such procedures will become incorporated into the benefit structure as they become more canon and expected by the insured. Other changes are planned as a result of patient requests, as revealed by membership surreys or

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108 as a result of marketing analysis. For example. in 1980 some plans began to include reconstructive surgery after mastectomy. Changes in the operating procedures, ranging from hours of opera- tion to services offered at the individual facilities, often occur as a result of changes in the utilization patterns or changes in patients' perceptions as reflected in the membership surveys. Changes in the structure of the program, such as location and Of f ins of facilities, often are in response to anticipated changes based on projections of number and characteristic of members routinely monitored by the Medical Econae ics Department . Monitor ing the Impact of Program Modif ications Largely through the activities of the Health Services Research Center, the Raiser/Oregon program is able to systematically monitor the impact of many of its program modifications. Particular attention is given to evaluation activities that are likely to contribute to the organization of health services within the larger Kaiser-Permanente organization. Many of the ma jar innovations that hare come f rom the Kaiser/Oregon program in the last twenty years were conducted as a special demonstration study wi th the careful evaluation strategy built into the original plan. Consequently, Xaiser/Oregon has very elegant data on the impact of many of the modif ications that have been made. A series of studier of impact of the efforts to meet the health needs of the medically underserved population addressed in the OEO population have appeared in the literature {Colombo et al., 1969; Creighton et al., 1970; Greenlick, 1971: Johnson and Azevedo, 1979) . This ef fort and the programs to improve the care to the elderly popu- lation demonstrate the rigor with which Kaiser/Oregon evaluate. the impact of many of its program modifications. Although they are - extrenely rigorous in design, they do not account specifically for the differential impact among individuals of varying risk or priority and are therefore at stage I$I of development. In contrast, the effort to address sudden inf ant death syndrome {SIDS ~ was monitored in a way that accounted for differential impact among the risk group, and is there- fore of stage IV. Env i Comments 1 Inf luences The Common ity Me community for which the Xaiser/Oregon program has ass~ed responsibility is defined by membership in one of the Raiser/Oregon health plans. Thus, Ka iser/Oregon can generate a lint of individuals in the member community as an enumeration of the denaeinator upon which to base assessments of the health status, health needs, or perception of health. Although not including all members of the c:on~unity, the HSRC has maintained a rich data base on a f ive percent sample of the

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109 community, and f requently examines the data base for various assess- ments of health status and services need. The Faiser/Oregon program has a community that differs f ram those of the other pilot s ites in one important respect. Over time, indivi- duals may elect to enroll or disenroll in the health plan, resulting in somewhat transient community. Although a substantial proportion of the community is long-term enrollees, the potential for disenrollment might act as a dis-incentive for the program to emphasize preventive health services that will not show results for many years. However, there is no indication that Kaiser/Oregon takes less than a fully aggress ive approach to health promotion issues as evidenced by their activities in the areas of stress reduction, weight loss, and smoking cessat ion . Organization of the Provide rs Were are a number of important aspects of the organization of the Raiser/Oregon program that have important influences on the practice of COPC. At a macro level, Kaiser/Oregon is not organized to provide primary care alone, but rather is organized to provide comprehensive health services that include pr imary care. This has two important implications. First, with the responsibility to provide or assure a full range of outpatient and inpatient services , there is the strong economic incentive to provide effective primary care services to its entire community in order to decrease the costs of relatively expensive secondary and tertiary care. Second, success in preventing the need for expensive tert iary care f rees resources (at least theoretically) that stay within the program and can be used to support the CO PC activities themselves. Two organizational variable. appear to particularly promote COPC within the Kaiser/Oregon program. First is the presence of a single medical record that incorporates all health care data for that patient independent of the provider or facility of service. Second, is the presence of the specialty of family practice within the program. This represents a studied change made in the Hess Kaiser area approximately f ive years ago. The Kaiser/Oregon program has been traditionally based on multispecialty group practice that continues not to incorporate family practitioners. Raiser/Oregon does not currently have a computer-assisted data system that routinely captures clinical information for all members. Although the f ive percent sample maintained by HSRC is quite useful in identifying health need. and health status of the membership, it does not permit the identif ication of specific individuals within the enrolled community in need of specif ic services. However, the clinical data system includes information on all participants of special efforts. such as the OEO demonstrat ion and the Med icare Plus proj eats descr ibed above. In these ef forts the data system was put to f ull use in tar- geting specif ic individuals for selected services, monitor ing the process of care, and assessing the impact of the program.

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110 The Raiser/Oregon program in currently studying the possibility of instituting an automated system to accommodate some of the data support f unctions for patient care as well as maintaining the appointment sys- tem and selected patient. registries. There is also some interest in developing a data system capability that will permit identif ication of patients with specif ic r isk prof iles that place them at risk to certain conditions such that they can be targeted for more aggreselve screening. Tnere is a particular interest in applying this format to Rome forms of cancer in which early intervention is critical. Organization of Financ ing Among the environmental inf luences af fectinq the development of COPC at Kaiser/Oregon, perhaps the most obvious is the organization of f inancing. IMOs have been the subject of considerable debate on the theoretical ef facts of preps id capitation on the incentive to prevent d isease and promote health. litany of the same arguments can be extended to the theoretical incentives for an HMO to identify and deal wi th health problems among its members, particularly, for those health problems that consume more resources if early intervention does not occur. A more recent development is the entry into the health care market of an increas ing number of prepaid practice forms, thus increas ing the competition for any 9 iven HMO. In Portland this has placed Kaiser/ Oregon in a more competitive posture in which competition is expressed through the mix of services in the various benef it plans. As competi- tive pressure has increased, Kaiser/Oregon has invested more effort in monitoring the potential for Adverse selection. (individuale with expensive service needs selectively choosing Kaiser/Oregon} as rela- t ively small alterations are made in the benef it plans. SUMMARY In general, the Kelser/Oregon program demonstrates a high level of development of the QOPC functions as summarized in Table 6.3. As a CO PC program, Xaiser/Oregon is unusual in the extent to which they systematically define and characterize the community and in the extent to which they routinely monitor the health status, utilization patterns, and consumer perceptions of the services they receive. For the first two of the COPC functions, Raiser/Oregon clearly demonstrates the state of the art. The Xaiser/Oregon program is also unique bang the study sites in the way in which it develops program modifications through altering the configuration of benefits within its different health plans. Many of the developments for carrying out the functions of COPC, while particularly well developed in the Kaiser/Oregon program, can be found in many of the older } - Os. mus, the health maintenance organization, as an organizational form for health services delivery, appears to share many of the underlying pr inciples of COPC, and may be conduc ire to the development of a COPC practice .

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111 TABLE 6 . 3 Compar ison of the Level of Development of the Ha jor Functional Elements of COPC in the Raiser/Oregon Program Ident if y Mod ~ fy De f ine and Community the Mon. i tor Character ize Health Health Impact of the Community Problems Program Modif ications ~ . ~ STAGE 0 STAGE I STAGE I I STAGE I I I S IDS ELDERLY ELDERLY PREVENT PREVErttr STAGE IV X ELDERLY S IDS S IDS PREVENT PREVENT refers to the effort that addressed the problem of improving , preventive services to the medically underserved children of the OEO demonstration project. SIDS refers to the activity that addressed the problem of sudden inf ant death syndrome. ELDERLY refers to the activity that attempted to improve the range of health services available to the elderly subset of the enrolled ca~u`,unity. Or . Lawrence 9 ides a large share of the credit for the program to the prevalence within the organization of individuals who are c:on=itted to the health of the entire community, who have a background in commu- nity medicine or public health, and who are innovative and willing to experiment with the organization of health services. Although many such people are within the Bealth Services Research Center, there is a very large number among the practitioner staff as well. Several impor- tant innovations including the emergency diagnosistic unit any number of special efforts in health promotion and health in the work place, were conceived and developed by the practitioners within the program (Raiser/Portland, 1979) .

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112 INTERVIEWS David Lawrence, M.D., Area Medical Director Merwyn R. Greenlick, Ph.D., Director, Health Services Research Center Tim Carpenter, Health Plan Manager John Thompson, M.D., Pathologist and Assistant Area Medical Director Judi Brenes, Coordinator, Health Promotion Mike Leahy, Area A - inistrator Pan Potts, M.D., Director, Emergency Services, Bess Kaiser Hospital Andrew Glass, M.D., Chief/Department of Oncology Than Lemert, M.D., Oncologist Mark Tager, M. O., Health Promotion Consultant Joy Gray, Health Educator Don Gallagher, Manager, unity Medicine Department Allan Weiland, M.D., Phyetcian-in~Charge, Vancouver Medical Office Margaret O'M~lley, R.N., Director, Have Health Agency Matt Stieffel, Director, Medical Economic Department

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113 REFERENCES Burnham, fir., and Freeborn, D.R. 1979. Oregon health survey: Initial f indings for HSA 1. Draft paper prepared for the Northwest Oregon Health Systems. Bu rnham , V., and Freeborn, D. R . 19 80 . Oregon health survey : Initial f inking for HSA 1 compared to f indings for ESA 2 and ESA 3. Draft paper prepared f or the Northwest Oregon Health Systems . Colombo, T.J. 1976. An HMO experience with an alcohol treatment program. Paper presented at the 1976 Group Health Institute, June 13-16, 1976, Denver, Colorado. Colanbo, T.J ., Freeborn, D.K., Mullooly, J. P., and Burnham, lt.R. 1979. The effect of outreach workers' educational efforts on disadven- taged preschool children' use of preventive services. American Journal of Public Health 69: 465-468. Colombo, T.J., Saward, E.W., and Greenlick, M.R. 1969. The integration of an OEO health program into a prepaid comprehensive group practice plan. American Journal of Public Health S9 641-650. Creighton, W.E., Colombo, T.J., Saward, E.W., and Greenlick, M.R. 1970. Developing a future for the der'tal group in a neighborhood health cents r-- Implications for the present. The Journal of the Oregon Dental Association, May, pp. 18-21. Freeborn , D . R ., Mullooly , J. . P ., Colo~nbo , T., and Burnh~ , V. 1978 . The effect of outreach workers' services on the medical care utilization of a d isadventaged population. Journal of Community Health 3 :306-320. Freeborn, D.K., and Pope, C.R. 1981. Client satisfaction in a health maintenance Organization: Providers' perceptions compared to clients' report. Evaluations and the Health Professions 4: 275-294. Greenlick, M.R. 1971. Medical service to poverty groups. Pp. 138-151 in The Raiser-Permanente Medical Care Program: A Symposium, A.B. Somers, ed. New York: The Commonwealth Fund.

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114 Greenlick, M. R. 1974. The function of data in the formulation of social policy. Pp. 197-199 in Proceedings of the Public Health Conference on Records and Statistics (I)HEW Pub. No. (HRA) 75-1214) . Washington, D.C.: U.S. Government Printing Office. Greenlick, M.R., Lamb, S.J., Carpenter, T.~., Fischer, T.S., Marks, S.D., and Cooper, W.J. 1983. Raiser-Permanente's Medicare Plus pro ject: A successful Medicare prospective payment demonstration. Health Care Financing Review 4: 8S-97. ,Hurtado, A.V., Greenlick, Fl.R., McCabe, M., and Saward, E.W. 1972. The utilization and cost of hose care and extended care facility services in a comprehensive, prepaid group pract ice program. Medical Care 10: 8-16. Johnson R. E., and Azevedo, D. J . 19 7 9 . Compar ing the med. ical ut il i zat ion and expend itures of low income health plan enrollees with Medicaid recipients and with low income enrollees having Medicaid eligibil- ity. Medical Care 17: 953-966. Raiser Permanente. 1983. Kaiser Permanente program history presentation for Kaiser-Permanente Executive Prog ram. Unpublished paper, July 15, l9 83 . Kaiser/portland. 1979. Programs Needed or Planned for the Future: Inventory Responses. Appendix B. Excerpt from Interim Report: Health Education, May IS, 1979. Kaiser/portland tn.d. ) Evaluation of Employee Health Promotion Program f ram the Employee Survey. Raiser/portland {n.d. ~ Health Services Research Center Data Systems. Background mater ial . Noel, R., and Combo, T.J. 1978. Moving the treatment of alcoholism into the medical mainstream. Alcoholism: Clinical and Experimental Research 2: 293-~6. Oleinick, A., and Mullooly, J.P. (n.d.) Epidemiology, health care utili- zation and economic charges for hayfever and asthma. Unpublished paper, Kaiser-Permanente Medical Care Program, Portland, Oregon. Pope, C.R. 1978. Consumer satisfaction in a health maintenance organiza- tion. Journal of Health and Social Behavior 19: 291-303. Vogt, T.M. 1979. Epidemilogic findings influencing the Raiser-Permanente medical care program: How data col lection pays off. Paper presented at the annual meeting of the American Public Health Association, November, 1979.