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You will be able to make these changes only during the Benefits Open Season or in conjunction with a qualifying life event. People were looking to the health plan where they could maintain their provider relations. Like other organizations with multidivisional structures, KP's corporate headquarters struggled to find the right balance between giving new regions the flexibility and autonomy they needed to respond to local market conditions and advancing KP's corporate goals and maintaining consistent policies.
Some of KP's corporate decisions benefited the organization as a whole but constrained the region's ability to respond to start-up demands in a challenging market. For example, the company required the region to repay its start-up debt with interest, at rates that some former KP—Carolina managers described as above market.
From the KP corporate point of view, the decision made sense given its experience in Texas, where the West Coast medical groups had been incensed about having to subsidize an operation that lost money for 15 years.
Moreover, it needed its investment repaid quickly, as its West Coast regions were clamoring for funds for information technology and facility upgrades. In our interviews, current and former KP corporate executives downplayed the significance of the debt service requirement in KP—Carolina's performance problems, but former KP—Carolina regional managers expressed a different point of view.
Similarly, in the early s, KP's corporate headquarters urged KP—Carolina and other regions to develop business plans for achieving and sustaining a 15 to 20 percent price differential from competitors. Faced with heated competition from network-model managed care plans, KP corporate headquarters jointly conducted a study with a major consulting firm and affirmed its commitment to the cost-leadership strategy.
The consulting firm encouraged KP to think about market share as an important success factor. The conventional wisdom was that with a good economic base, marketplace presence was a key factor. At the time, KP—Carolina had just reported its first profitable year and had priced its product above the average for the market in order to reflect its true costs of operation including service on the start-up debt.
Again, the opinions on the wisdom of this corporate decision differed. As one CPMG leader stated:. We were encouraged, to use a mild word, to reduce our operating infrastructures enough to support a 15 to 20 percent lower price point.
But we were unable to cover the cost of what we were doing. The solution was applied uniformly across the organization, which I think in retrospect everybody believes was a problem. Current and former KP national executives disagreed, arguing that the problem was not the wisdom of the strategy but, rather, its poor execution by the medical group. Corporate executives cited the inability or unwillingness of regional leaders—especially in the CPMG—to build a sustainable business model based on tight cost control.
These constraints were said to include limits on plan and benefit design as well as on advertising, sales, and marketing. Interview participants disagreed about whether the failure to achieve the requisite operating efficiencies to sustain this corporate objective resulted from problems of ability, willingness, or circumstances. The general business literature indicates, however, that simultaneously achieving revenue growth and cost control in a start-up is daunting even under ideal market circumstances e.
Like many organizations, KP routinely transferred personnel laterally in order to shift needed expertise from one region to another and to enhance career development. Several interview participants reported, however, that this did not work well in the case of KP—Carolina. Not surprisingly, senior KP—Carolina managers disagreed, contending that the lack of entrepreneurship stemmed not from inexperienced management but from national corporate constraints on innovation.
As one said:. The original leadership brought in to start this region was supposed to replicate, not innovate. The job was to replicate the KP model in North Carolina. There was no room for entrepreneurship, nor would it have been welcomed. We were given binders of material that we were supposed to use—staffing ratios, financial reporting formats, marketing materials, benefit plans, graphic standards, staff training tools, even floor plans.
They wanted us to stick to the recipe. It was the Oakland way—or no way. As the competition from less restrictive managed care products intensified, KP—Carolina tried to complement its group-model HMO with a point-of-service product and an IPA-model product. Two problems immediately arose. First, KP—Carolina did not have the organizational capability to effectively manage an extensive network of contracted providers.
Its business systems could not track members as they moved through a more open, networked delivery system, pay claims in a timely and accurate manner, or monitor utilization across loosely affiliated physicians and hospitals.
As one former CPMG employee noted:. We didn't know how to pay a claim. We hadn't had to pay very many claims.
We had a lot of capitated and prepaid specialty arrangements and all of a sudden we started getting claims in, and I remember when 50,, you know, six months of claims went unpaid. It was outrageous. KP—Carolina managers and medical directors found it hard enough to build the familiar group-model delivery system from scratch under less than hospitable market conditions.
Simultaneously creating and managing a network model so far removed from KP's core competence proved impossible. Moreover, by trying to straddle the gap between staff-model and network-model product markets, KP—Carolina diverted precious resources from its core product and its core constituencies. The original group-health model concept did not get the attention that it needed and started to deteriorate. This seemed a good way to build enrollment, increase volume, and counter the growth of competing products.
Reflecting on KP's flirtation with network models in North Carolina and other regions, several interview participants commented that the flawed strategy nearly cost the company its soul. Perhaps this is the most important internal lesson that KP as an organization could learn from its North Carolina experience. It is easy for outside observers to be critical of a business strategy and outcome after the fact.
However, reflecting on our analysis of the North Carolina experience, David Lawrence, KP's CEO at the time, concluded that the regional failure was due to an internal corporate failure to understand how to expand:.
KP expanded with a missionary zeal that substituted for careful, thoughtful planning and development of the core modules required to incrementally build a viable business. We did not learn from other industries, follow established pathways for successful expansion that have occurred in other industries, etc. It is an important lesson for us.
We operated with a California bias and had no real understanding of what was required to accomplish, execute a start-up, and to build a successful business.
I do not think the model was wrong; rather, it was in the execution. Stated differently, I do not believe we have tested whether or not the model can be successful yet. We thus conclude that the KP experience in North Carolina illustrates in microcosm the complex interdependencies that determined the fate of a KP expansion effort, not to mention similar efforts by other PGPs around the country.
The demise of several KP regional expansions reinforces the importance of the numerous interlocking pieces that are necessary to foster a market in which a prepaid group practice can exercise its competitive advantage. It is clear that in North Carolina none of the important factors was pointing in the right direction.
However, while KP used to be able to charge less for more comprehensive benefits than others were charging for less comprehensive benefits, KP now has a smaller price advantage. KP's historical business model attempts to build efficient-scale operations and vigorously pursue cost control while maintaining acceptable levels of quality and service.
Achieving low overall costs requires enough enrollees to support the internalization of most specialties into the medical group as well as access to production inputs e. By achieving low overall costs through efficient, high-volume operations, KP can offer low premiums and low out-of-pocket expenses as well as more comprehensive benefits.
Furthermore, in its fully perfected version, the Kaiser model would offer more coordinated care delivery through a group-practice culture and internal coordination among medical and hospital service providers in exchange for a more restricted choice and, sometimes, less convenient access. The historical business model clearly did not succeed in North Carolina. Where KP has been successful in entering markets, an important factor has been strong backing from influential local organizations e.
Local sponsors such as unions have provided an enrollee base and lent important political support. On the West Coast and in Colorado, Kaiser had strong backing from the AFL-CIO, which liked its emphasis on comprehensive benefits and preventive medicine and demanded that employers offer Kaiser as an alternative to traditional insurance. Regional expansions have also been successful in Georgia with more than , members and in the Washington, D. While there were widespread losses in the competitive Atlanta market, KP's ability to consolidate allowed it to reach a critical mass of enrollees.
Kaiser has also continued to grow steadily in Colorado, Hawaii, and on the West Coast. It was able to build on the West Coast from the s through the s, when the managed care industry was young, and independent competing medical groups were scarce.
It achieved a network scale and scope that would be difficult to replicate today, when the industry is mature and competitors abound. When Kaiser expanded outside its core markets in the s, as was the case in North Carolina, the industry was maturing, and sophisticated competitors were plentiful.
The North Carolina case illustrates the difficulties of replicating the vertically integrated model in new geographic markets under these circumstances. Kaiser Permanente maintains a dominant position on the West Coast, and hybrid entities that embody some but not all the elements of prepaid group practice can be found in many metropolitan areas. In its most recent report, Kaiser Permanente's national membership in nine states and the District of Columbia remained flat at 8.
But the trend in the health care marketplace generally is toward broad-network insurance products divorced from provider systems, retrospective rather than prospective payment, a purchasing framework that emphasizes copayments at the time of service rather than a cost-conscious choice at the time of insurance enrollment, and an institutional framework hostile to the principles and practices of managed competition.
In six of the eight geographic regions that Kaiser Permanente serves, the two largest customer groups are state and federal employees. In the other two, the largest enrollee groups are federal employees and a public school system. In the FEHBP, the benefits are not as standardized, but the Office of Personnel Management has required that the benefit packages offered be fairly comprehensive.
However, not all is perfect even in the ideal purchasing environment. In the CalPERS program, Kaiser is concentrated in urban areas in California, where health plan competition still works, which means that with a statewide premium, the PGPs enjoy the luxury of not having to operate in rural areas that are costly because of local provider monopolies but where the self-funded PPOs do operate.
It is likely that certain markets, such as most rural or commuter areas, may not have the geographic conditions to sustain a profitable private-sector PGP, even when these conditions are met. What can private employer and public policymakers do to make market environments more hospitable to the PGP model of care delivery?
The essential insight of managed competition, as a reform, is to divide the provider community into competing economic units and then to offer employees a responsible choice with premiums that reflect the differences in per capita cost, in order to give them an incentive to choose the efficient providers Enthoven If a critical mass of employers were able to do this in any market area, managed competition advocates still claim, they would create the environmental conditions in which efficient delivery systems could enter, market their superior value for the money, and achieve economies of scale.
The following elements must be present if a PGP is to have access to the employee not just employer market: a broad choice of health plans; risk adjustment to mitigate adverse selection; an employer contribution that allows employees to retain any savings resulting from an economical choice; a level regulatory playing field among HMOs, insurers, and self-insured plans; and reliable, comparable information about the quality of care and consumer satisfaction. Recent research has shown wide variations among providers in the resources used to treat the same conditions and produce the same outcomes Fisher et al.
Employers might offer employees a price-sensitive choice among existing HMOs and encourage HMOs to develop selective networks to improve their performance. The all-inclusive network favored by employers in the single-source model is sure to be ineffective. Alternatively, under the protection of the Employee Retirement Income Security Act, employers might develop several selective PPOs, each of which would offer the preferred services of a different network of providers. If there are effective IPAs in a market, employers might build their choices on them or even share the gains created by the most efficient providers by offering them bonuses for achieving performance goals.
The focal points for these networks would likely be different hospitals and their staffs. The idea is to be sure that those employees who choose efficient providers realize the savings generated by their choices. Despite the high expectations, PGPs have fared poorly in the market in recent decades. Group- and staff-model HMOs have survived only where they constitute a large portion of the local market, offer an adequate choice of physicians, and gain from economies of scale similar to those of nonintegrated competitors Hurley et al.
PGPs have had a great impact on the American health care system and continue to offer high-quality, cost-effective care to millions of patients in particular regions and communities.
Yet their future remains unclear. KP was not the only HMO to have faced competitive challenges. Nationally, no group- and staff-model HMOs have performed well over the past two decades. In June , the group and staff models had 7. By July , with In July , group and staff models served 7.
Membership in staff models actually declined, while membership in group models mainly Kaiser Permanente grew slowly and lost market share to faster-growing models, such as IPAs and mixed models.
The models that rely on established providers and facilities can grow much faster than group and staff models that must recruit and develop their own doctors and facilities. By the early s, some group- and staff-model HMOs, seeking to attract employers that wanted a single source of health insurance, sought innovations and merged with or acquired wide networks of traditional providers to offer alongside their groups.
After experiencing three years of no growth, it brought another group into its network and created a wide network of fee-for-service, solo-practice doctors. In these cases, market conditions created by the employer single-source and employee contribution policies that did not highlight cost differences forced health plans to abandon the pure staff model InterStudy Some health plans have tried to combine the virtues of organizational integration with the attractions of contractual promiscuity by wrapping a network of independent physicians around a core of an integrated group practice.
In Washington and Idaho, however, the Group Health Cooperative has combined a core prepaid group practice with a contracted network of solo and small-group practices, thereby preserving its market share.
But it has not been able to leverage the distinct virtues of integrated efficiency and broad choice into a comparative advantage and so remains a niche player in a market increasingly dominated by broad network-insurance products and fee-for-service payment Robinson As a vertically integrated organization that combines an insurance entity with multispecialty group practices and, in some regions, hospitals, KP possesses particular strengths and weaknesses.
A PGP cannot be built overnight. For decades, KP and the Group Health Cooperative have been working out the kinks and links in the financing and delivery systems. Hence, the most general lesson of our analysis is that the successful introduction and proliferation of prepaid group practice into markets with little or no experience with the model depend on the conjuncture of several supportive conditions.
These include employers willing to offer a choice of carriers because PGPs cannot succeed as a single source ; employers willing to structure the offering to employees so that the employee making the choice gets most, if not all, of the savings; a framework that mitigates adverse selection; a regulatory framework that imposes equal burdens on PGPs and their competitors; a supply of high-quality providers hospitals and specialists willing to contract with PGPs on terms similar to those granted to others; and a high enough population density to permit the enrollment of a critical mass of members within a referral area sufficient to support the multispecialty group practice with most of the secondary care specialists represented.
All this suggests that while PGPs can play an important role in market-driven reform, without the right mix of supporting factors, a variety of other, more flexible and robust models will also be needed. We gratefully acknowledge the numerous interview participants who gave generously of their time and insights, especially Dr. The Kaiser Permanente Institute for Health Policy provided grant support and information, but the analysis and conclusions are solely our own.
James Bernstein, M. William Brandon, Ph. Christopher Conover, Ph. Ray Coppedge, M. June 20, Allen Feezor, M. Claudia Ghianni, M. Bill Gillespie, M. Nancy Henley, M. Eugenie Komives, M. May 6, Anna Lore, B. Don Madison, M. Joe Morrissey, Ph. Sandra Newton, M. Lynette Omar, M. Derek Prentice, M. March 19, Pam Silberman, Ph. Lynn Spragens, M. Jill Steinbruegge, M. Stephen Stemkowski, Manager, Premier, Inc.
Herman Weil, Ph. Glenn Wilson, M. Wilson was a leader in the organization and financing of eight community-sponsored prepaid direct-service group medical practices, including the Community Health Program, Cleveland, Ohio, which eventually became Kaiser Permanente of Ohio KP-OH March 19, These comments are cited as KP Institute May 6, Milbank Q. Author information Copyright and License information Disclaimer.
Regulators, Purchasers, and Providers What were the barriers to building a viable prepaid group practice? Regulatory Uncertainty after Market Entry In the mids, KP—Carolina, as one of the first HMOs and the first prepaid group practice in the market, faced a fluid and uncertain regulatory environment. The Politics of a Purchaser: The North Carolina State Health Plan KP achieved some of its greatest successes in other regional expansions by enrolling large numbers of members from either private-sector unions or public employee systems.
Open in a separate window. Resistance from the Medical Community Cohesive physician organizations can find ways to inhibit the entry and growth of prepaid group practices. Carolina Permanente Medical Group and Organizing the Provision of Medical Care In addition to meeting the two-tiered marketing challenge, KP's success depended heavily on efficiently providing medical care through the group-practice model.
As one interview participant noted: In those markets where [KP] had created a favorable cost structure, the local medical group has essentially taken and executed the responsibility for making that happen. KP Institute 2. National Corporate Constraints Like other organizations with multidivisional structures, KP's corporate headquarters struggled to find the right balance between giving new regions the flexibility and autonomy they needed to respond to local market conditions and advancing KP's corporate goals and maintaining consistent policies.
As one CPMG leader stated: We were encouraged, to use a mild word, to reduce our operating infrastructures enough to support a 15 to 20 percent lower price point. UNC Inexperienced Regional Management Like many organizations, KP routinely transferred personnel laterally in order to shift needed expertise from one region to another and to enhance career development. As one said: The original leadership brought in to start this region was supposed to replicate, not innovate.
A Mismatch of Model and Market? Prepaid Group Practice, Whither the Future? Acknowledgments We gratefully acknowledge the numerous interview participants who gave generously of their time and insights, especially Dr.
David Coulter, M. June 19, June 10, References Enthoven A. New England Journal of Medicine. The History and Principles of Managed Competition. Health Affairs. Annals of Internal Medicine. Excelsior, Minn. HMO Directory, 5. HMO Directory, 6. HMO Directory, 7. HMO Directory, 8.
Oakland, Cal. Meeting notes, May 6. The Balanced Scorecard.
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