Quality Assurance Kaiser Permanente

Quality Assurance: Kaiser Permanente

Case Management Programs are More Concerned with Reducing Costs Than with Improving the Quality of Care

Rather than relying on generalized statements about case management programs, focused research on Kaiser Permanente (Kaiser) shows an egregious example of a "profits over patients" mentality in case management. By delaying, misdiagnosing, undertreating or not treating at all, Kaiser evidently save millions of dollars, until It gets caught. For example, in June 2010, the California Department of Managed Health Care (DMHC) fined Kaiser a $75,000 administrative penalty for unreasonably delaying diagnosis and treatment of autism for Andrew Arce. According to the DMHC, due to Kaiser's delays and denials, Andrew's treatment was delayed for more than a year and he did not receive needed treatment until he was damaged by Kaiser's delays and denials (Kaiserthrive.org, 2010).

Binding arbitration boards are also finding that Kaiser delays adequate treatment. For example, in November 2008, a Valencia, California couple was awarded $5 million by a binding arbitration panel because Kaiser was failed to timely diagnose and treat Timothy Howard's "transient ischemic attacks (TIA) of the retina which resulted in a devastating stroke" (Kaiserthrive.org, Courtesy of Vicki Travis of the Kaiser Papers, 2009). Though the treating Kaiser neurologist was aware of the need for more extensive testing, she did not order it. Misdiagnosed and underdiagnosed, Mr. Howard continued to suffer TIA, and then had a massive stroke for the incorrectly diagnosed, untreated condition. Since the stroke, Mr. Howard, a once-healthy 46-year-old Middle School assistant principal: is wheelchair bound with no use of his left arm and weakness on his left side; needs 24/7 assistance with all life aspects; suffers cognitive and mental deficits; is clearly unable to work. The cost of his future care is estimated in the millions of dollars (Kaiserthrive.org, Courtesy of Vicki Travis of the Kaiser Papers, 2009).

Finally, cases like the Arce's and Howards' are not isolated incidents; rather, it appears that Kaiser deliberately, methodically puts costs over quality of care. In October 2010, Dr. Richard Della Penna M.D., a former Kaiser physician and one of the country's foremost experts in treatment of the elderly and special needs patients, announced that he will file a lawsuit against Kaiser for its deliberate plan to treat only 5% of the 57,000 chronically ill patients for which Kaiser received $13 Billion in Medicare funds. Directly violating the Medicare Modernization Act of 2003 and the Medicare Improvements for Patients and Providers Act of 2008, Kaiser deliberately avoids proper care management that would provide vital yearly physical, functional and psychosocial assessments for 95% of those 57,000 elderly and special needs patients (Kaiserthrive.org, 2010). Furthermore, Dr. Della Penna alleges that when he complained to Kaiser about its failures, "he was rebuffed, isolated, marginalized and ultimately forced to resign" (Kaiserthrive.org, 2010). Even a cursory look at Acer, Howard and Della Penna shows that one of the largest case management programs in America is clearly focused on profits rather than quality of care.

2. The Limitations and Strengths of a Typical Case Management Program:

Research reveals a number of limitations in a typical case management program. First, as Kaiser shows, there is an obvious monetary incentive to underfund treatment: Kaiser controlled the diagnoses and treatment of Arce, Howard and 57,000 other patients and in those examples alone, by delaying scheduling, misdiagnosing, undertreating or not treating at all, Kaiser evidently intended to save millions of dollars. The Kaiser examples also show that case management programs can be difficult to oversee and govern: by creating an atmosphere in which conscientious medical personnel are "rebuffed, isolated, marginalized and ultimately forced to resign," Kaiser can keep a tight, secretive rein on its practices.

An in-depth study of case management programs in Florida, North Carolina and Oklahoma found other common limitations: there is a lack of standardized reporting that makes it difficult to document improvements, which the study calls a "glaring weakness" in case management programs (Silberman, JD, DrPH, Poley, & Slifkin, PhD, 2003, p. 26); in addition, there is a lack of communication between case management programs, which have "no forum or responsibility" to exchange "best practices," which slows improvement of medical treatment overall (Silberman, JD, DrPH, Poley, & Slifkin, PhD, 2003, p. 32); finally, the data accumulated and kept by case management programs varies in quality and quantity because their each case management program has its own understanding of the data that should be collected and how it should be collected, kept and used (Silberman, JD, DrPH, Poley, & Slifkin, PhD, 2003, p. 32).