State fines Kaiser again

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State fines Kaiser again The HMO's second such penalty in a year targets its

handling of patient complaints at nine hospitals.

By Tracy Weber and Charles Ornstein, Times Staff Writers

July 26, 2007

 

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Kaiser Permanente will be assessed a record fine today for its haphazard

investigations of questionable care, physician performance and patient

complaints at its California hospitals, according to state HMO regulators.

 

The California Department of Managed Health Care said it will levy a $3-million

fine against Kaiser, the largest HMO in the state, with 29 medical centers and

more than 6 million members. If Kaiser makes necessary improvements, agency

director Cindy Ehnes said, she will forgive $1 million of that.

 

The penalty marks the second time in a year that Kaiser has been publicly

rebuked and fined for glaring breakdowns in oversight.

 

The state's latest inquiry grew out of its investigation into problems that

forced the closure last year of Kaiser's kidney transplant program in San

Francisco. Hundreds of patients were endangered when Kaiser forced them to

transfer to its own fledgling program from established transplant centers at

outside hospitals.

 

Last August, the state fined Kaiser $2 million for the transplant debacle, and

the HMO agreed to pay an additional $3 million to promote organ donation.

 

Even then, Ehnes said, the question remained: " How could it happen? "

 

To answer that question, the state focused on whether Kaiser was properly

handling — or even knew about — allegations of subpar care at its hospitals

statewide. Inspectors examined 246 files involving complaints, quality-of-care

concerns and other issues from four hospitals in Kaiser's Northern California

region, and four in its Southern California region.

 

The investigation did not examine whether individual patients had been harmed,

only on how well Kaiser monitored the quality of patient care.

 

" A patient has to be sure that if they have a problem … the health plan has

their ears open to hear those complaints and their arms available to tackle any

of the problems that have arisen, " Ehnes said in an interview. " That's what our

concern was, that those ears in particular seemed to be sometimes deaf. "

 

A top Kaiser official on Wednesday called the state's 51-page inspection report

" thorough and actually very constructive. "

 

The managed-care agency found that under the HMO's massive umbrella, individual

hospitals had their own rules: Some rigorously pursued potential medical

mishaps; others did not.

 

The vast majority of the report focused on a system called " peer review, " a

standard quality-assurance mechanism at hospitals in which doctors' committees

examine patient cases to determine if the care was appropriate.

 

Inspectors found large differences among hospitals in how often questionable

cases were being referred for peer review. In Northern California, one hospital

might refer as much as 20 times as many cases as another.

 

Even when peer review was performed appropriately, it did not always result in

sufficient efforts to improve care, the report says. In a quarter of the 57

cases examined by the state in which peer review committees found a quality

problem, follow-up was incomplete.

 

In one case, a peer review panel examining pediatric care determined that a

doctor provided an " unacceptable standard of care, " but it doesn't appear anyone

alerted the hospital's top doctors to the findings so they could act.

 

Regulators also found several instances in which doctors were in charge of

investigating cases in which the treatment they provided was called into

question.

 

Investigators said they stopped short of determining whether those reviews were

handled appropriately.

 

" You can't really move on from the taint of looking at your own case, " said

Marcy Gallagher, the chief state surveyor on the Kaiser inquiry and the head of

health-plan surveys at the managed-care agency.

 

Gallagher said inspectors identified at least three occasions on which

committees at Kaiser hospitals inexplicably stopped their review of troubling

cases before they were complete. Kaiser was asked to finish those reviews, she

said.

 

Overall, the report found that the HMO " lacked the ability to verify consistent

handling of complaints throughout its medical centers or to determine whether

serious or chronic problems were being addressed. "

 

The nine Kaiser hospitals examined as part of the report are in Woodland Hills,

Fontana, Baldwin Park, West Los Angeles, south Sacramento, San Rafael, South San

Francisco, Fresno and San Francisco. The state did not identify which hospitals

had the weakest systems.

 

Bernard Tyson, Kaiser's executive vice president of health plan and hospital

operations, stressed that the review did not take issue with the quality of care

delivered. " The survey identified the areas in which there were shortcomings,

and we have corrected those shortcomings or are well on the way to correcting

those shortcomings, " Tyson said.

 

He added that the HMO is focused on shoring up the systems for handling member

complaints and quality assurance at its hospitals — and not on the fine or the

public relations fallout of two rebukes in as many years.

 

Unlike other HMOs, Kaiser is both a health plan and a hospital system. It works

exclusively with an affiliated group of physicians called the Permanente Medical

Group. Kaiser, a nonprofit organization, had nationwide revenue of $34.4 billion

last year and net income of $1.3 billion.

 

Ehnes said Kaiser officials had been cooperative during the review process,

" from the level of the national board on down. "

 

Although the report did not look at patient harm per se, Gallagher said the

findings are troubling.

 

" You are creating incredible risk when you don't have an oversight or a

checks-and-balances system, " she said. " I hate to think that we have to wait for

somebody to get harmed before we say, 'Wait. Let's make sure the safeguards are

in place.' "

 

The report said Kaiser officials and board members received " extensive reports "

on patient satisfaction scores and other quality indicators — such as cancer

screenings and childhood immunizations — but no reports on trends or problems

found at individual hospitals during confidential reviews.

 

Kaiser closed its Northern California kidney transplant program in May 2006

after The Times exposed how hundreds of patients were stuck in limbo for months

— with little hope of receiving new kidneys — because the HMO had failed to

properly handle paperwork transferring them to its new program in 2004.

 

In Kaiser's program, twice as many patients died on the waiting list in 2005 as

received kidneys, The Times found. The statewide pattern was the reverse: Twice

as many patients received kidneys as died.

 

All the while, the Kaiser patients had to undergo prolonged dialysis, which

removes impurities from the blood but can lead to fatal complications and reduce

prospects for a successful transplant.

 

In the report to be released today, the state reiterated its contention that

Kaiser knew only general information about the start-up of its kidney program,

even though such a massive rollout had never been tried before. The HMO did not

measure the effectiveness or adequacy of the start-up or monitor the timely

access to transplant services for hundreds of its patients moved to Kaiser's new

program, the report says.

 

Under the managed-care agency's oversight, about 2,000 Kaiser kidney patients

were transferred to other programs.

 

" We have now, in many ways, done the concluding chapter to this whole kidney

issue, " Ehnes said.

 

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tracy.weber

 

charles.ornstein

 

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Begin text of infobox

 

Actions promised

 

Kaiser Permanente has agreed to overhaul its quality oversight system to ensure

that member complaints and concerns about questionable care are consistently

reviewed at its 29 California hospitals. The HMO has agreed to:

 

• Pay a $3-million fine, which will be reduced to $2 million if it corrects its

problems quickly.

 

• Create a reporting system so HMO leaders can monitor how care is delivered

and quality-of-care complaints addressed.

 

• Draft a uniform set of standards for peer review — the process by which

doctors' committees examine patient cases to determine if the care was

appropriate.

 

• Form a member concerns committee in Southern California to examine member

grievances and complaints, similar to what is underway in Northern California.

 

• Audit physician peer review programs to ensure they are accurately evaluating

— and correcting — potential quality issues.

 

• Reconfigure computer systems to better track quality reviews.

 

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Source: California Department of Managed Health Care

http://www.latimes.com/news/local/la-me-kaiser26jul26,0,2551268.story

 

 

" A trail blazed by an elephant becomes a roadway. " Burmese proverb

 

" The care of the Earth is our most ancient and most worthy, and after

all our most pleasing responsibility. To cherish what remains of it and to

foster its renewal is our only hope. " Wendell Berry

 

 

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