Kaiser Permanente is diversifying in response to declines in Medicare Advantage star ratings and threats from large insurers and retailers.
The Oakland, California-based integrated system suffered a setback in its Medicare Advantage business when it experienced one of the industry's biggest declines in quality ratings this year, with four of its seven plans losing out on bonus payments. At the same time, Kaiser Permanente is investing in technology and partnering with rival health systems and insurance companies to help members stay connected to the system outside its service area.
In an interview, Chief Medical Officer Dr. Andrew Bindman spoke about what led to the star ratings letdown and how Kaiser Permanente can compete with Amazon after its One Medical acquisition. The interview has been edited for length and clarity.
Kaiser Permanente was one of the first nonprofit insurers to offer a on-demand virtual care. What is the current status and future of that venture?
Our Get Care Now program is very popular and continues to be something that we absolutely are supporting to allow our members to be able to access services through telephone or video. Kaiser has conducted more than 1.2 million phone and video visits through Get Care Now since launch [in September 2021].
One of the things we're trying to learn more about is how we can use tools to help our members find solutions to care that meet the problems they have, and to direct them in ways that are consistent with their values and interests. We're really trying to provide options and information to members so they can self-manage, to the extent that they want to do that.
Amazon Prime members can now access One Medical for $9 a month. How do you compete with that?
Our members have an average tenure with our health plan of over 11 years. If a member contacts us for an urgent care need and uses Get Care Now, one of our health professionals not only makes use of the information provided at the moment, but they have access to that person's entire electronic health record. We use the Epic system throughout our enterprise.
Unlike entities that are trying to just focus on the front end, immediate service, we're understanding your health history. Because we are an integrated system, focused on taking care of the whole person, we have a really robust set of information upon which to incorporate new concerns in ways that we think will help to solve your problem more effectively.
Retailers and health insurers offering direct care have argued they're better off not owning hospitals. Why is Kaiser and Geisinger's Risant Health taking the opposite tack?
Geisinger Health System is much more than a hospital system and is focused similarly on population health and promoting value-based care.
There are many different ways that Risant may emerge. The partners that we will work with will probably vary in different communities.
There's been tremendous interest in our acquisition of Geisinger and there are a lot of other systems that are reaching out to us to ask about their opportunities to work along with us. We're evaluating those on a case-by-case basis to make sure that the values align. I wouldn't say that the configuration of the assets will be exactly the same in each of the entities.
What led to the decline in Kaiser’s Medicare Advantage star ratings?
There's been quite a bit of change over time with how CMS assesses stars for different [Medicare Advantage] plans. Over time, for example, they have changed the weighting related to different metrics, like the Medicare [Consumer Assessment of Healthcare Providers and Systems] survey has increased relative to some of the traditional clinical measures of quality.
Coming out of COVID-19, Kaiser Permanente, like many health plans around the country, experienced quite a bit of disruption related to not only who we were taking care of, but the workforce that was available to do that. Like other health plans, this challenged some members’ access to care and the experience of care. That was the area that had the most impact on our star ratings for the upcoming 2024 cycle.
We are somewhat unique as a health plan because of our integrated nature. That means that when there is disruption anywhere in our full, wraparound care, we are held accountable in ways that are perhaps more visible than in other health plans that don't have the same type of relationship with their providers. We're very focused on it. We've done a lot of work to address some of the workforce challenges coming out of COVID.
We've done a tremendous job of hiring nurses, and strengthening our primary care physician base. We value our partnership with labor and are thrilled that we've come to an agreement and very much believe that this will contribute to being able to have a strong relationship with our workforce to meet the needs of our members. That impacts all aspects of quality and experience.
Do you think the star ratings program needs to change?
Much of our focus on quality measurement as a country is focused on process measures like "Did a particular member get a mammogram?" Those processes are important to look at, but they are an insufficient step to really maximizing member outcomes. If we don't measure outcomes, we can't truly address the question of dealing with inequities. People do start at a different place with regard to their social circumstances and their expectations for care.
I think not just the star ratings, but our whole regulatory apparatus should be updated to focus more on outcomes. I also think we are beginning a journey to look at our quality measures through the lens of equity. I'd like to see greater guidance from the federal government so that we can make sure that the way of looking at quality through the lens of equity is done consistently across organizations.