The Future of Employer-Based Health Care Coverage: A Conversation with Institute for Health Policy Advisory Board Member Kevin Schulman, MD

Editor’s Note:  This post and accompanying Q&A is authored by Ben Wheatley with the Kaiser Permanente Institute for Health Policy.

In a recent Perspective published in the New England Journal of Medicine titled, “Shifting toward Defined Contributions — Predicting the Effects,” Kevin Schulman, MD, discussed the increasing number of employers that are moving to defined contribution strategies in providing health care for their employees.

For employers, this move limits their financial exposure to rising health care costs by shifting the cost burden. Instead of negotiating rates with health insurance companies, employers contribute a capped amount toward their employees’ care, which gives them a suite of options for choosing coverage – along with added obligations in paying for their care as costs increase over time.

Kevin Schulman, MD

Kevin Schulman, MD

As the trend towards defined contribution grows, the nature of employer-based coverage begins to change. Institute for Health Policy Advisory Board Member Kevin Schulman, a professor of medicine in the Duke University School of Medicine and director of the Center for Clinical and Genetic Economics, discusses the implications of this shift.

Ben Wheatley: Ten years from now, will employer-based coverage as we know it still be around?

Kevin Schulman: This is one of the most interesting questions in health policy today. There are many problems with the current employer-based coverage system: it can limit flexibility in job choice, limit entrepreneurship, and, in a global marketplace, it can make American exports look more expensive next to products from countries where health care is funded differently.

The migration to defined contribution begins to break the bond between employment and coverage. Under this new approach, employees are really the ones purchasing their health benefits, and thus pay more of their own health care costs and will want to have more flexibility in their benefit choices.

Read the entire interview.
Please note: The views expressed in this article are not those of Kaiser Permanente.

Categories: Guest Blogger
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A Perfect Storm Brings Health Care, Government and Business Together for a More Sustainable DC

There was a “perfect storm” of activity in the nation’s capital last week, and if you weren’t tuned in closely, you might have missed it.

The Sustainable DC pledge awaits formal signatures from health care representatives signifying their commitment.

The Sustainable DC pledge awaits formal signatures from health care representatives signifying their commitment.

This perfect storm was not another Superstorm Sandy. In fact, one might argue that one of the aims of this perfect storm was to build resilience to any such storms in the future. This perfect storm brought together representatives from 21 different health care organizations and local government officials at Kaiser Permanente’s Center for Total Health pledging to make the District of Columbia “the most sustainable city in the United States.

So what makes this newsworthy? The health care sector is certainly no stranger to coming together under the umbrella of sustainability. Over the past 20 years, the sector has been leading its very own “green revolution,” with hospitals and health care systems of all sizes looking hard at their contributions to environmental waste and pollution and what they must do to flip the equation and support more environmentally sustainable health care approaches.

What makes the Sustainable DC effort special is its focus on a single urban community, on bringing together leaders from health care, government and business sectors in a particular place, concentrating their efforts across governance, jobs and the economy, equity and diversity with the goal that, “By 2032, the District will be the healthiest, greenest, most livable city in the nation by using sustainability solutions to address core challenges.” The Sustainable DC plan outlines specific goals, targets and actions to get there. And the plan makes it clear that health care organizations to be at the table to bring the mighty vision to fruition.

Hospitals in America contribute an estimated 8 percent of greenhouse gas emissions, generate more than 2 million tons of waste each year and draw upon natural resources like water in ways that often counteract efforts to support the health of individuals and communities. Recognizing this paradox, many health care leaders have joined efforts like the Healthier Hospitals Initiative, Practice Greenhealth and Health Care Without Harm to green their own health care systems.

Kathy Gerwig, chief environmental stewardship officer for Kaiser Permanente, chronicles this green movement in her recent book, Greening Health Care: How Hospitals Can Heal the Planet. In the book, she notes the reasoning behind why health care organizations would move to join forces with each other and government to move the needle on environmental health:

“In the final analysis, most health systems engage with their communities not because they are incented to do so by federal and state tax law, but because they are mission-driven organizations that care deeply about the health of their communities. They know that individuals’ health depends on the health of the communities in which they live, work, learn, and play, and that the health of those communities depends on a healthy environment—health-sustaining air, water, soil, and all natural resources. They strongly believe, on the basis of compelling evidence, that when they invest their dollars and their expertise in promoting healthy social and physical environments, they are benefiting their communities and contributing to the health of everyone.”

That mission-driven energy was palpable on October 23, 2014. The energy in the room was exciting, collegial and activated. There was much talk of the sustainability progress that is already converging in DC – from an extensive array of green roofs and LEED-certified buildings across DC to the build out of the Metropolitan Trail to provide safe, physical activity and active transportation options. And there was a clear conviction expressed by health care leaders who were gathered, as well as the Mayor’s office, that this coming together for a more sustainable DC was just setting the stage for a convergence of efforts that would echo progress even beyond DC limits.

We can only hope that, as DC leads the way in sustainability, so goes the rest of the country.

Representatives from DC area health care organizations gather with Mayor Vincent Gray at the Center for Total Health after the signing of the Sustainable DC pledge.

Representatives from DC area health care organizations gather with Mayor Vincent Gray at the Center for Total Health after the signing of the Sustainable DC pledge.

Kaiser Permanente applauds the Sustainable DC plan, and we are pleased to be among the pledge-signers and the hosts for this momentous step forward. We have pledged our support and look forward to working with fellow health care system leaders to advance the goals outlined in the plan.

Kaiser Permanente physician director for the Center for Total Health, Ted Eytan, along with Keith Montgomery, executive director for the Center, nicely set the stage for the day’s event in their welcome remarks. Ted offered his follow-up reflections in a blog post that summarized the vision for total health that everyone in the room intuitively if not concretely echoed that morning. He writes, the Sustainable DC plan is “not just about the environment, it’s about everything that goes into creating an ‘equitable, prosperous, society.’”

You can watch the full signing ceremony in this video.

Total Health Questionnaire: Kathy Gerwig

Kathy Gerwig is Kaiser Permanente’s Vice President of Employee Safety, Health & Wellness, as well as the organization’s  Environmental Stewardship Officer.

Kathy Gerwig

Kathy Gerwig

Q: In a few words, what does Total Health mean to you?
A: Having joy and meaning in one’s life, enhanced by good health.

Q: What’s your first health-related memory?
As kids, my brother and I played in a desert. He came down with Desert Fever and I didn’t. That’s when I became aware of his vulnerable immune system, and the courage it takes to live with a disability.

Q: Which person, living or dead, is your health hero or role model?
My father was a surgeon who got a Purple Heart and Bronze Star for service in WWII because he kept operating on wounded soldiers while the hospital he ran was being bombed. Throughout his career, he was all about the patients.

Q: What is your favorite food?
Environmentally sustainable sushi.

Q: What do you value most in your work? What inspires you to continue?
A: I get to work with smart, caring, passionate visionaries who are driven to serve others.

Q: If you could change one thing in health care, what would it be?
A: Less politics. More compassion.

Q: Where would you most like to live?
Where I live now, the San Francisco Bay Area.

Q: What do you consider your greatest achievement so far?
A: Capturing the stories of lots of my heroes in the book “Greening Health Care, How Hospitals Can Heal the Planet.”


Categories: Questionnaire

Domestic Violence: A preventable public health problem

Domestic Violence InfographicThis month and every October, we pause to reflect on the profound impact that domestic violence has at the individual, community and national levels. It is well documented that one in four American women and one in fourteen men will be subject to domestic violence during their lifetime. We know more today than ever before about the science behind domestic violence — meaning its short-term and long-term health impacts.

Kaiser Permanente has a long track record of raising awareness and taking action on this topic for the benefit of the many lives it insures (many of whom are employees of the company). Its efforts were recognized last month by Peace Over Violence (a Los Angeles based non-profit whose goal it is to eliminate violence against women, youth and children) in the form of a corporate humanitarian award. This honor came about because of Kaiser Permanente’s leadership in partnering with the NO MORE campaign to raise public awareness about this issue via funding for programs serving survivors.

This week, the Institute for Health Policy website published an updated version of the article I authored in 2012 that highlights Kaiser Permanente initiatives and the gains over the last decade. A shining example is the implementation of an innovative approach for domestic violence prevention that was first piloted and launched in Kaiser Permanente’s Northern California region. In the words of Brigid McCaw, MD, director of that region’s family violence prevention program: “Transforming the health care response to domestic violence requires going beyond the traditional focus on didactic training for clinicians. Kaiser Permanente’s successful ‘systems model’ approach demonstrates that domestic violence prevention can be effectively incorporated into everyday health care services.”

You can read the story in its entirety at the Institute for Health Policy site.

Breast Cancer: Perspective on the Experience

In continuing observance of Breast Cancer Awareness Month, we are once again sharing Total Health Radio podcasts on related topics.  These are the final two episodes in a series of three all about breast health — from genetics to life as a cancer survivor.

Check out this second episode in the series, “Breast Cancer: After Diagnosis.”


And this third episode called, “After Cancer: A New Normal.”

Categories: Audio, Podcast

Research Improves Detecting Ovarian Cancer While Sparing Women Unnecessary Surgery

Elizabeth Suh-Burgmann, MD

Elizabeth Suh-Burgmann, MD

Elizabeth (Betty) Suh-Burgmann, MD, chair of gynecological oncology for Kaiser Permanente’s Northern California Region, has been doing research to improve clinical care of gynecologic cancer throughout her career.

With ultrasounds being performed on patients more often, occasionally abnormalities are discovered that doctors weren’t initially looking for. Dr. Suh-Burgmann was interested in small, complex, ovarian masses discovered in women over age 50, who are at greater risk of ovarian cancer than younger women. While difficult to treat successfully in its later stages, ovarian cancer has a good prognosis if found early. However, the only way to know immediately if these small masses are cancerous is to remove them surgically, leading some women to have surgery for non-cancerous masses.

Dr. Suh-Burgmann reviewed the charts of approximately 1,800 KP NCAL members and identified 1,400 who had these masses. Her research showed that the rate of malignancy was quite low among the group of small, complex, ovarian masses she studied. The findings were published online Sept. 8 in the American Journal of Obstetrics and Gynecology.  We sat down with her recently to talk about her work and the findings of this study.

Q:  Your research resulted in new clinical practice guidelines. Tell us about them.

A:  In April we implemented new radiology templates and practice recommendations in Northern California that are designed to reduce the number of unnecessary surgeries while identifying cancers more readily. Providers and radiologists like using them because they have a clear, recommended, evidence-based path for what to do based on the ultrasound and clinical characteristics of masses. Our shared goal is to spare women unnecessary surgery while providing assurance that worrisome masses receive prompt evaluation.

Q:  Why is ovarian cancer so difficult to detect?

A:  Unfortunately, it’s not always possible to distinguish between cancerous and noncancerous masses accurately on an ultrasound. Furthermore, levels of the CA125 protein, which is specific to ovarian cancer, are elevated in only half of women who have early-stage disease. In the majority of women with ovarian cancer, the disease has begun to spread before they have any symptoms.

Q:  What kind of masses did you study and why?

A:  When a woman has an ovarian mass, there’s always a concern that it’s cancer. Large masses are always removed and tested, but there has been no clear guidance for what to do about smaller masses, which could be cancer or, much more likely, benign tumors or cysts. I looked at masses under 6 centimeters that radiologists described as “complex,” which means that they have ultrasound characteristics that raise some concern for cancer.

Q:  How did you do this study?

A:  With the help of Yun-Yi Hung, PhD, at the Division of Research, I looked in KP HealthConnect for women age 50 and over who had these small, complex masses, no symptoms of disease, and no elevated CA125 levels, to see what happened to them. I was here many evenings, reviewing charts. I got really efficient at it.

This is the first large, population-based study that actually looks at the risk of ovarian cancer in this group. The actual rate of malignancy was quite low. Only seven out of 1,362 of these masses were actually cancer—just one in 200. That’s a lot lower rate than most women’s-health providers have been taught to assume. Also, no masses that remained stable for more than 7 months later turned out to be a cancer or borderline tumor.

Categories: Research
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Breast Health and Genetics: What You Should Know

In recognition of Breast Cancer Awareness Month, we will be highlighting a series of three episodes of Total Health Radio over the next few weeks that focus on breast health — before, during and after a cancer diagnosis.

In this episode, we explore breast cancer screenings and the role of early detection in survivability. Our host speaks with OB/GYN Cristina Amaya about breast cancer screenings, and genetic counselor Monica Alvarado talks about the role our family history plays in a breast cancer diagnosis.

Total Health Questionnaire: Loel Solomon

Loel Solomon is vice president of community health for Community Benefit at Kaiser Permanente. He lives in the Bay Area with his wife and two great kids. 

Loel Solomon, Vice President of Community Health for Kaiser Permanente

Loel Solomon, Vice President of Community Health for Kaiser Permanente

Q: In a few words, what does Total Health mean to you?
A: I am connected to loved ones, doing meaningful work in the world, getting sleep and taking care of myself…and that I am living in a neighborhood and workplace that supports my healthy choices.

Q: Which person, living or dead, is your health hero or role model?
Jack Geiger – he saw that healthcare is necessary but insufficient to secure the blessing of health.

Q: What is your favorite food?
Dim sum – truth be told.

Q: What do you value most in your work? What inspires you to continue?
A: It’s the people I have the good fortune to work with, both at Kaiser Permanente and our partners.   I keep on learning about all the different pieces that contribute to health – how it’s all connected – and how we all have such a vital piece of the health puzzle.

Q: In your opinion, what is the most underrated way to improve health for individuals?
A: Creating “optimal defaults” to shift behavior – by using principles of behavioral economics and behavioral design.  Some people are also calling this “choice architecture.”  It’s powerful stuff!

Q: Where would you most like to live?
Exactly where I live – in the East Bay of Northern California.  Natural beauty, diversity, great food, walkable cities – and a place that is generating so much  great thinking and doing around healthy communities.

Q: What do you consider your greatest achievement so far?
A: First, being raised by two great kids.  They (and their peers) are the hope of the world.  And a ton of fun.  Second, co-founding the Convergence Partnership, a group of national funders and the CDC which have really helped bring equity and multi-sectoralism into the conversation about what really drives health, and how to invest in it.    

Q: If you could have dinner with any three people, living or dead, who would you pick?
A: Yikes.  A great grandmother I never net.  She was a card, apparently.  Nelson Mandela, FDR, the Dalai Lama, Studs Terkel, Robert Reich, Khaled Hosseini.

Leadership Perspectives: Good Health Starts Where You Are

Editor’s Note: Today, we launch a recurring feature on the Center for Total Health Blog. “Leadership Perspectives” is a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Elisa Mendel, national vice president of HealthWorks & Product Innovation for Kaiser Permanente, who shares her thoughts on place-based health.


How much time would you guess you spend at work each year? Would you be surprised if I said it’s something like 2,000 hours?

Elisa Mendel, VP of HealthWorks & Product Innovation for Kaiser Permanente

Elisa Mendel, VP of HealthWorks & Product Innovation for Kaiser Permanente

Compare that to the time we spend with our doctor — maybe 15 minutes once or twice a year? That’s why place-based health is so important. At its core, good health starts with us — where we live, work, learn, and play.

That’s one of the reasons Kaiser Permanente partnered with leading national organizations to launch Thriving Schools. The idea is that schools are the hub of every community. Our work in schools focuses on four key areas: healthy eating, active living, school employee wellness, and a positive school environment. One of the active living programs is called Fire Up Your Feet. Fire Up Your Feet’s fall campaign launches October 1, and it encourages kids to walk to school with their parents, giving them much-needed exercise and some quality time together.

Another initiative I really love combines the childhood enthusiasm for play with the workplace. It’s called “Instant Recess.” A manager or wellness champion schedules time with their team —usually about 10 minutes. Everyone stops what they’re doing, and one of the team members leads the group in dancing and exercise. People are moving, getting their blood pumping, and laughing together. It’s had amazing results, because when you’re doing the chicken dance with your supervisor, suddenly things feel a little less stressful.

Kaiser Permanente piloted this in various work settings — call centers, IT, and even the ICU. One of the ICU patients heard the staff doing this Instant Recess every day on the floor and she was determined to get out of bed so she could be wheeled out to participate in the fun.

There’s no limit to the benefits of healthy living. It can lift spirits and deliver real business results. One study in the Journal of Occupational and Environmental Medicine showed that employees who ate healthy and exercised regularly were up to 27 percent less likely to be absent from work for health reasons.

Good health is becoming a national movement. Find your “healthy,” and start to share good health close to your home.

Domestic Violence: It’s a Health Issue

October is Domestic Violence Awareness Month — a good time to pause and consider just how many people are affected by domestic violence and sexual assault. The numbers are astounding. According to the National Coalition Against Domestic Violence, an estimated 1.3 million women are victims of physical assault by a domestic partner each year. And one in every four women will experience domestic violence in her lifetime.

Adults aren’t the only ones affected. Every year, nearly 1.5 million high school students experience physical abuse from a dating partner. One in three adolescents is a victim of physical, sexual or emotional abuse.

This episode of Total Health Radio talks about what teen dating violence looks like and some of the warning signs parents and friends should be watchful for. Guest Nancy Schwartzman, the inventor of the Circle of 6 mobile app, shares ways that young women can both prevent and cope with sexual assault.

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