9.09.2007

What is it like working for Kaiser? Let's start in the emergency department.

I have a few friends who work for Kaiser (Permanente Medical Groups), and I often wonder if they are happy working for an HMO. Here are their (collective) responses to some very common questions. (I'll break up the responses in various posts...to keep it bite-sized). These are just their opinions, observations, or experiences...not necessarily facts, truths, or gospel.

The Players:
Emergency Medicine Physician
Medicine hospitalist
OB/Gyn attending
Peds
Surgery

Let's start in the ER!!
The Emergency Attending


So, what's the ER like at Kaiser?
It's a nice facility, and of course there are constant upgrades (which is both good and bad). The patients are working class folks, which is nice. They are more-or-less compliant with follow-up, and outpatient visits are very easy to arrange.

Upgrades bad?
Sometimes stability is nice. Consistency. Satisfaction. "Upgrades" to the computer programs lead to delay in processing. Upgrades sometimes are not needed...and certainly shouldn't be encouraged to be trendy. When something is working...just leave it alone.

Do you see many non-kaiser patients?
Not really. I'd say that I see maybe 80-90% Kaiser patients. Kaiser patients are nice, and a good group to work with. They are reliable, working-class, mostly speak English (thereby helping expedite flow thru the ED), and have PMDs. They are not usually drug-seeking, and would rather be home than in the ED.

I hear that Kaiser doesn't give the docs much autonomy. Do you find your practice is stifled?
A bit, I guess. But, keep in mind that protocols are more your friend than your foe. If you have a patient, and they fit within 'the protocol' things are on 'autopilot.' The nurses, techs, PAs, CNP, everyone is on the same page from the very first record of the patient's chief complaint. This means things get done without you actually having to be there to do/order them. This is usually a very good thing. Likewise, when it comes time to disposition a patient....there are protocols. This alleviates arguing with consultants, or faltering on borderline cases. You feel comfortable discharging patients that you may otherwise worry about because 1) you're following a protocol, 2) you know that your colleagues are doing the same thing 3) and the patients have good follow-up. Kaiser has clinics for everything. If you believe a patient needs admission for something, you may be surprised to learn that there may be a clinic that can supply all the patients inpatient needs.

Are you worried about malpractice issues since Kaiser, in a sense, is telling you how to practice medicine?
Yes and no. I try to do the best I can, realizing that mistakes will be made. I do worry about bad outcomes, for multiple reasons, not just litigation. But, I feel (relatively) protected since risk management cases go to arbitration, instead of a jury trial. However, Kaiser will settle a case...which seems to make everything better. But I've seen colleagues get screwed if the settlement exceeds the amount reportable to the medical board (and that amount is very low, like 30 thousand dollars). Then, you're suddenly dealing with the medical board for your license because Kaiser decided to settle. Suddenly you realize that (like all organizations) Kaiser is about protecting Kaiser. So, they may settle a case that you'd actually prefer fight...but practically, you don't really have a choice. Many physicians have to employ their own attorneys despite having 'Kaiser attorneys' to be sure that it is their own interests (and not those of Kaiser) are at the forefront. So, you're not as protected against litigation as one might think.

How's the money?
I probably make about 30% less than colleagues on the outside. And I work more. Full time for Kaiser is 40 hours a week. That's an obscene amount of hours for ER work, rotating shifts and all. Not to mention the hours you stay past your shift tying loose ends and such. If I worked even half the number of shifts at another place, I'd easily make the same money.

But don't the benefits make up for what lost in income?
I don't think so....unless you retire in your early 60s and live well into your late 80s. Maybe, at some point in your life...it'll balance. But, staying at a place for 20-30 years of your life (all of your adult life), with the hope of a golden retirement....is actually costing you lots of money. Especially if you consider all that's lost in doing so. Additionally, some of the docs actually have insurance policies to protect their pensions. Ask them why and they'll say they've seen docs screwed out of their pension in one way or another.

You seem to pooh-pooh on the pension, which is seemingly the greatest aspect?
Among Kaiser docs, the pension is known as the golden handcuffs. The doctors feel an obligation to stay their entire career or lose most of their pension.

Put it this way...Kaiser pays you, let's say 30% less than you'd make elsewhere. But that 30% "lost" is actually going toward your pension, benefits (sick leave, disability, vacation, etc). Good stuff.

But, let's say you work somewhere not Kaiser. You take that 30% and create your own 'rainy day' account (for your 'sick leave', FMLA, maternity leave, vacations, etc.). You have disability insurance on your own. And health benefits are usually offered by the EM groups and partnerships...you just have to buy-in (so you do have to pay for that too). You invest a portion of your earning into a diverse financial portfolio including domestic and international property, stocks/bonds/mutual funds/etc. That total competes with (and very possibly exceeds) Kaiser's salary.

You can't actually believe that Kaiser's 'giving' you something. Why would they pay you more than market? You can't believe that the benefits are *costing* Kaiser money. That wouldn't be good business. It's like deducting my allowance for food costs, then advertising that I get to eat "for free." If they deduct your salary to pay for the benefits...they are not 'gifts.' Sometimes I hear people refer to Kaiser's "great benefits" as 'gifts' of some sort. Gifts they are not.

So...to make things easy, and not nit pick, let's say the total package is comparable*.

But there are other factors to consider...like your tax liability (i.e. how much the government is going to take from you), and how much (and how hard) you have to work to get the money.

So, what about these other factors?
Well, as an employee, you cannot write off...much of anything. You pay lots of taxes, and you can only write off a few things. As a partner, or IC, you can write off much more. In the end, since you end up spending quite a bit of money doing business, your tax liability may be lessened.

At Kaiser, you have to work 40 hours a week for 10/10 time (full time with the comparable* salary), as mentioned. On the outside, you work maybe 32 hours week. So, even if we agree that the pay is comparable*, you're working a bunch of extra time for that same pay. By the same token, if you actually worked 40 hr/wk on the outside, you'd make a considerable amount more, even after accounting for the benefit package.

But, you don't see major trauma at Kaiser...so it seems like the work is easier.
Perhaps in some ways. With the protocols, easy dispositions, and lessened risk of lawsuits...there may be less stress. However, non-kaiser patients can still sue you. As mentioned, there are the settlements that may adversely affect you. But overall, I guess the stress is less.

Keep in mind, major trauma isn't seen (regularly) at many community EDs, so that's not very unique. The Kaiser ED is very busy, and rarely quiet. Since I'm always moving, and frequently have no opportunity to eat, urinate, or check my email...I'm not sure I'd classify it as a 'tea party.' We do not sleep on a night shift. And the patients can be very demanding...which is draining in a different way. Overall, eventhough you see less patients, they are not necessarily not-as-sick, and you actually spin your wheels much of your shift, making you inefficient, giving the illusion that you're surfing the net the entire shift only seeing 1.75 patients per hour. The reality is you're running...most of the shift. Doing scut work, and non-physician tasks. Besides, I'd rather bust my ass, see more patients, do more doctor stuff when I'm at work...while making more money, working less shifts, allowing me to enjoy more time off.

What's the most difficult part of working in the ED for Kaiser?
At Kaiser, there are lots of 'rules.' Guidelines, protocols, and constant hoops to jump thru in order to keep step with the latest regulatory entities. It's very overwhelming. Many of us feel that the Corporation is much more concerned about the paperwork, and how things look in retrospect (to surveyors, auditors, lawyers, etc), than really making the environment better for patient care. As a Corporation, they attempt to adhere to regulations to the point of skittishness. No real physician advocacy in my experience, therefore no real patient advocacy. But, on paper, to outsiders, things look good.

The computer systems!! They are very cumbersome, and inefficient. They slow you down (and I'm a relatively computer literate person, I type fast, and love electronic charting). The ED doesn't flow well. Things aren't set up to maximize the physician. Much of our time is spent putting pieces of paper in the chart. For instance, we are to print our H&Ps. Sounds simple enough. But what that actually means is, apart from actually doing it....load paper into the printer....attempt to print....trouble shoot the computer....troubleshoot the printer....attempt to print (again)....walk over to printer....if all pages didn't print (or are not clear) you may have to reprint....sign the paper....find the chart (and this can take upwards of 10 minutes)....put the paper with the chart. And this is only the H&P. Repeat for the medication requisition, the aftercare instructions, the prescription...per patient!! This process can easily take 20-30 minutes per patient. Just printing paper!! And, it's still required (by joint commissions I guess) that the original paper H&P (the one we used to write on before the computers) still must contain information. So you have to write times, a brief history/diagnosis, and sign it. After all this, the computer crap still isn't enough. This can be fixed...but there isn't enough interest as of yet. And, when patients are waiting for the physicians for an hour or five...our satisfaction scores (thus our profit sharing) diminish. You are punished for systemic failure.

Speaking of satisfaction scores...
Not unique to Kaiser, but still a pain in the ass. It's very deflating to be 'graded' by patients who are given this *one* opportunity to express their frustrations with the *entire* ED experience...and the results are linked to the physician. So, if they cannot find parking, or the security guard wouldn't let them into the back....or if the nurse was rude, the coffee cold, the room too hot...whatever...they will use this 'survey' as a mechanism to express their frustration (which they should). The problem occurs when the physician is either rewarded, or reprimanded, based on these survey scores. Much of which they played no part.

Finally, the politics are superincumbent. I've been told that per diem docs work for Kaiser years and years, and never 'get picked' for full participation. Like in other political work environments, it's expected that one kiss major ass, and the right ass, to gain recognition. Meaning, being 'available' to work the undesirable shifts, fill-in at the last minute, and basically play the intern role all over again. Silent and content while getting screwed. Even partners are not immune to the effects of top-heavy, unilateral decision-making by non-clinical administration. Being made to come in early for 'time-outs' pre-op, but not get compensated for working 'overtime.' Staying late after a shift to care for a critical patient, sometimes for hours...uncompensated. Being made to travel to far away places in order to get the hours you need for full-time. Being made to work longer shifts (11 - 12 hours) to save money for the organization...on a whim, or at the recommendation of outside consultants. Lack of control and ability to self determine...

Are there good things about working for Kaiser that hasn't been mentioned?
The nurses do their jobs well, for the most part. Since Kaiser agreed to many of CNAs terms, including major pay raises and the agreement to not make their managers, 'managers' (i.e. exempt from the union), the nursing jobs are pretty well paying. However, despite the money, the nurses don't seem any more pleasant or happy to be there. Actually, it seems like since they make good money...they actually aren't catered to. They aren't made to feel special. I guess if the job is a 'good job' there's always someone in line to replace you. So, as a unit, the nurses are strong. But talking with an individual nurse, they seem....frustrated and unappreciated. These feelings aren't well concealed.

Other good things: Since most of the patients have insurance (i.e. Kaiser) their payer mix is excellent. (So you'd expect that the physicians should actually be paid much, much more than they are). Again there are very few dispo problems, follow-up problems, liability isn't constantly on your mind, and most of the staff are excellent. It's a "good job" for the ancillary personnel...so you have good people. Consultants are available. You may have to transfer people for various things, but most facilities will take a Kaiser patient (because they will get paid). This makes transfers, when they are necessary, much smoother.

As mentioned, follow-up is great. I can usually successfully get a patient into a specialty clinic the very next day...or within 2 days for sure.

Would you recommend an ER doc work for Kaiser?
It depends on what you want, where you are in your career, and your personality. Most ER docs today are very lifestyle oriented, outspoken, and expecting to be paid well. In my experience, Kaiser doesn't encourage (actually they discourage) being outspoken. If you want to be at Kaiser a long time you mustn't criticize 'administration' too vehemently. Actually, you mustn't criticize at all. It is what it is, period. You cannot influence the style, attitude, or practice with good suggestions and constructive criticism. You will piss them off...and they may conspire against you. 40 hours of rotating shift work is not conducive to a good lifestyle, actually, it inhibits your ability to balance medicine with personal time. And, the money, as discussed, is not quite equal to the outside when all things are considered (like your time).

But, if you're a quiet, go-with-the-flow-no-matter-how-asinine-things-are, kind of person. One who likes protocols, and is seeking the illusion of 'security' (while the pension is not guaranteed, and they can kick you out, just with more difficulty, as a partner so don't be fooled)...perhaps Kaiser is for you. There's still quite a bit of running around...so by no means is it a sleepy ED. If you don't mind being at the hospital or sleeping 80-90% of the time that the rest of your family is off. If you feel more comfortable with the possibility of having a pension waiting for you (like all the workers at Enron, Delta, etc), and are willing to allow the Corporation to invest/control your retirement/investment capital on your behalf (for good or bad). If you have health issues...and can work 10 years and become vested into their lifetime health benefit program (albeit the Kaiser Health program...which may or may not be good for your particular illness). You may be a good match for Kaiser as an ER doctor.

Sounds like it's not a great match for you, what would you say is the single biggest problem with Kaiser for you?
Lack of self-determination with respect to career, working environment, and ability to make money make Kaiser suboptimal for me long-term.

The ability to work elsewhere, have your own business, or the freedom to be more in control of your destiny in non-existent. There are no branch-points. You will always make (close to) the same (inadequate) money your entire career...and once you retire, you'll get 60% of that (inadequate) salary. There is no entrepreneur opportunity...no place for creativity or control of the workplace. You'll never be financially as free as you think you should be...free to travel, invest, live comfortably. As an employee, your work doesn't extrapolate to more money or respect. As Kaiser makes record profits and builds new hospitals all around the state....the doctors are seeing way too many patients, and aren't getting a piece of the pie...even as patients choose (or are given) Kaiser for the sole purpose of having the ability to see a doctor.

Additionally, it seems to me that many decisions are made behind the closed doors of top executives (despite the declaration of democratic partnership) - and the effects of those decisions are often acutely felt by the frontline physicians and the patients they treat. This happens without their input, or consideration for their impact on the ability to render appropriate patient care. Outside consulting firms are hired, and their recommendations/opinions, supersede many (free) suggestions from their very own docs. Actually, suggestions are not appreciated, and many once enthusiastic 'Kaiserized' doctors are just 'putting in their time' and 'counting down the days to retirement.' Many I talk to feel completely and utterly stuck...have too much vested to just walk away (with their pensions, and home loan programs), but feel powerless to improve (or participate in) their work environment. As orders are handed down to them...they are silenced...underpaid...and unable to even venture out into the world and start a business or work elsewhere part-time. In many ways, it feels like a trap - just like cheese under a box...

Overall?
I find it a great transition...but have no desire to pay my $30-50K dollars, or whatever it may be (via additional payroll deduction) to become a 'partner'. I enjoy my time...and have too many ideas, hopes, dreams, aspirations...to be happy with Kaiser as it is today. There is certainly the foundation for a great HMO, and I understand the necessity of hierarchy, but the doctors have to feel as if they are truly apart of an organization that has their best interests in mind. And today's Kaiser has not accomplished this. The illusion of security is attractive in our insecure world, and to sacrifice your freedom may seem like a fair trade...at first. But, I have yet to meet an old Kaiser doc who doesn't seem bitter...and is crossing off days on a calender to retirement.

Caveats...
There are multiple Permanente Groups, and a great many facilities - of course I'm sure are happy Kaiser docs, and I'm sure there are places where things are completely different from the experience described. We welcome other points of view....and please be reminded that this is just the opinion of the ER docs I spoke with...


*comparable - maybe, maybe not. but let's just agree that it is.

15 comments:

ten out of ten said...

I don't get why they work there.

ER doctor said...

Sometimes, especially in the Los Angeles Area, it's the only job open. As a resident, their offer sounds exceptional. Or, it's a quick/easy job to get...especially if you know someone on the inside. Most residents who train in LA *do* know someone on the inside...someone who graduated a year or two before they did.

Anonymous said...

I am very interesting in seeing what the Kasier Hospitalist think about their practice. I am in the process of applying for a job there. Please post that one next. By the way, I love your blog. Very informative.

ER doctor said...

i was planning to do the ob/gyn...but my friend is sooo busy, i'm still waiting for the responses. so, i just might move on to medicine hospitalist...probably later this week....

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