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1. What is the relationship between the insurance planand the provider network (especially physician groups andhospitals)?
2. Is the relationship cooperative and positive, oradversarial, negative, and suspicious?
Kaiser Permanente
KP Model A Prepaid Integrated Delivery System
How is the Kaiser Permanente model of care delivery differentfrom most American health care organizations?
Unique Approach
Kaiser Permanente’s long record of achievements in providinghigh-quality, affordable health care to its members and itscommunities is directly related to the unique way we organize,finance, and deliver health care to members.
Unlike most American health care organizations, KaiserPermanente is not just a health insurer, not just a hospitalsystem, not just a physician group. It is all three of these things– a non-profit, prepaid, integrated delivery system.
Setting KP Apart
The combination of the following characteristics distinguishesKaiser Permanente from most other health care organizations:
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Prepayment – Prepayment, or capitation, of the annual memberpremium means that under Kaiser Permanente’s comprehensive coverageplans members face no economic barriers to medically necessarycare, as determined by their personal physician(s). Pre-paymentaligns incentives between the health plan and the member so thatboth benefit when care is delivered.
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Integration – All of the insurance, administrative, and clinicalfunctions of health care are provided within a partnership of threeentities (health plan, hospitals, physician groups) workingtogether with aligned goals for quality of care, efficiency, andaffordability. In addition, all aspects of patient care areintegrated for coordination and efficiency across specialties,sites of care, and life stages.
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Group Practice – The self-governed, multispecialty PermanenteMedical Groups are committed to collaboration and coordination ofcare, evidence-based medicine, and wise use of resources.
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Nonprofit – The nonprofit status of the health plan andhospitals means that all revenue margins are invested in improvedpatient care infrastructure and in health-related community benefitprograms.
A Seamless Partnership
A Seamless Partnership of Health Plans, Hospitals, and MedicalGroups
Since its founding in 1945, Kaiser Permanente has defined theintegrated model of health care financing and delivery through itsunique partnership among three entities:
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Kaiser Foundation Health Plans – Nonprofit regional health plansthat contract with members (individuals and groups) for prepaid(capitated) comprehensive health care services.
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Kaiser Foundation Hospitals – Nonprofit corporations that ownand operate or contract for hospital facilities and services forthe care of Kaiser Foundation Health Plan members.
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Permanente Medical Groups – Self-governed, multispecialtymedical groups in each KP region that contract exclusively withKaiser Foundation Health Plan and Hospitals to provide medicalservices to members.
In contrast to the economic competition among doctors,hospitals, and health plans in the non-integrated system, allentities within the KP system share the same, aligned economicincentive: the efficient delivery
of high quality, total health care to members.
In Kaiser Permanente’s multispecialty medical groups, physiciansand other clinicians:
o Share experience and expertise to identify and implementsuccessful practices.
o Share a vast clinical knowledge base that continuously supportsquality improvement.
o Coordinate care across disciplines to provide continuity of careand reduce duplication and waste.
o Practice physician-led team-based care (physicians, nurses, caremanagers, technicians, and others).
o Monitor and report the quality of care.
o Invest in sophisticated quality improvement tools and strategiesthat are not available to solo practice or small groupphysicians.
Preventive health and wellness services are emphasized to helpkeep members healthy.
Kaiser Permanente’s size, scope, and integrated structureenables it to take full advantage of state-of-the-art informationsystems supporting clinical practice, administrative functions, andcommunications between and within KP and its members.
