ABOUT KAISER PERMENENTE:

Kaiser Permanente

Type	Nonprofit
Founded	1945
Founder(s)	Henry J. Kaiser Sidney R. Garfield
Headquarters	Oakland, California, USA
Key people	George Halvorson, Health Plan and Hospitals CEO John H. Cochran, M.D., Federation Executive Director
Industry	Healthcare
Revenue	? $34.4 billion USD (2006)
Net income	? $1.3 billion USD (2006)
Employees	181,900 total 167,300 employees (2007) 14,600 physicians (2008)
Website	kp.org

Kaiser Permanente is an integrated managed care organization, based in Oakland, California, United States, founded in 1945 by industrialist Henry Kaiser and physician Sidney Garfield. Kaiser Permanente is a consortium of three distinct groups of entities: the Kaiser Foundation Health Plan and its regional operating subsidiaries, Kaiser Foundation Hospitals, and the autonomous regional Permanente Medical Groups. As of 2006, Kaiser Permanente operates in nine states and the District of Columbia, and is the largest managed care organization in the United States. The name comes from the founder, Henry Kaiser, and the Permanente Creek.

Kaiser Permanente has 8.6 million health plan members, 167,300 employees, 14,600 physicians, 35 medical centers, 431 medical offices, and $1.3 billion in net income on $34.4 billion in operating revenues. The Health Plan and Hospitals operate under state and federal non-profit tax status, while the Medical Groups operate as for-profit partnerships or professional corporations in their respective regions.

Structure and governance

Kaiser Permanente provides care throughout eight regions in the United States. Each of these regions comprises two or three (and, in the case of California, four) distinct but interdependent legal entities. This structure was adopted by Kaiser Permanente physicians and leaders in 1955.

National structure

The two types of organizations which are purported to make up each regional entity are:

• Kaiser Foundation Health Plans work with employers, employees, and individual members to offer prepaid health plans and insurance. The health plans are purported to be not-for-profit and provide infrastructure for and invest in Kaiser Foundation Hospitals and provide a tax-exempt shelter for the for-profit medical groups.
• Permanente Medical Groups are physician-owned organizations, which provide and arrange for medical care for Kaiser Foundation Health Plan members in each respective region. The medical groups are for-profit partnerships or professional corporations and receive nearly all of their funding from Kaiser Foundation Health Plans. The first medical group, The Permanente Medical Group, formed in 1948 in Northern California.

In addition, Kaiser Foundation Hospitals operates medical centers in California, Oregon and Hawaii, and outpatient facilities in the remaining Kaiser Permanente regions. The hospital foundations are purportedly not-for-profit and rely on the Kaiser Foundation Health Plans for funding. They also provide infrastructure and facilities that benefit the for-profit medical groups.

Regional entities

Kaiser Permanente is administered through eight regions, including one parent and five subordinate health plan entities, one hospital entity, and nine purportedly separate, affiliated medical groups:

• Northern California
  • Kaiser Foundation Health Plan, Inc. (KFHP)
  • Kaiser Foundation Hospitals (KFH)
  • The Permanente Medical Group, Inc. (TPMG)
• Southern California
  • Kaiser Foundation Health Plan, Inc. (KFHP)
  • Kaiser Foundation Hospitals (KFH)
  • Southern California Permanente Medical Group (SCPMG)
• Colorado
  • Kaiser Foundation Health Plan of Colorado (KFHPCO)
  • Colorado Permanente Medical Group, P.C. (CPMG)
• Georgia
  • Kaiser Foundation Health Plan of Georgia, Inc. (KFHPGA)
  • The Southeast Permanente Medical Group, Inc. (TSPMG)
• Hawaii
  • Kaiser Foundation Health Plan, Inc. (KFHP)
  • Kaiser Foundation Hospitals (KFH)
  • Hawaii Permanente Medical Group, Inc. (HPMG)
• Mid-Atlantic (vicinity of Washington, D.C., including Maryland and Virginia)
  • Kaiser Foundation Health Plan of the Mid-Atlantic States Inc. (KFHPMA)
  • Mid-Atlantic Permanente Medical Group, P.C. (MAPMG)
• Northwest (Northwest Oregon and Southwest Washington)
  • Kaiser Foundation Health Plan of the Northwest (KFHPNW)
  • Northwest Permanente, P.C. Physicians and Surgeons (NWP)
• Ohio
  • Kaiser Foundation Health Plan of Ohio (KFHPOH)
  • Ohio Permanente Medical Group, Inc. (OPMG)

In addition to the regional entities, in 1996, the then-twelve Permanente Medical Groups created The Permanente Federation, a separate entity, which focuses on standardizing patient care and performance under one name and system of policies. Around the same time, The Permanente Company was also chartered as a vehicle to provide investment opportunities for the for-profit Permanente Medical Groups. One of the most dubious ventures of the Permanente Company is Kaiser Permanente Ventures, a venture capital firm that invests in emerging medical technologies.

Governance

Each entity of Kaiser Permanente purports that it has its own management and governance structure, although all of the structures are interdependent and cooperative to a great extent.

Kaiser Foundation Health Plan and Hospitals

Kaiser Foundation Health Plan and Hospitals has a single Board of Directors which is the ultimate governing body. George C. Halvorson is the chairman of the Board and the chief executive officer of Kaiser Foundation Health Plan and Hospitals. In this capacity, Mr. Halvorson is sometimes referred to as the chairman and CEO of Kaiser Permanente, although he is not a director for any of the Permanente Medical Group boards or an officer of any of those organizations. Halvorson leads a cross-regional management team that directs health plan and hospital operations across the Kaiser Permanente regions. Each region is headed by a regional president, each of whom report to a member of the national leadership team. The Kaiser Foundation Health Plan and Hospital Board of Directors consists of fourteen members including Mr. Halvorson. The other thirteen members of the Kaiser Foundation Health Plan and Hospital board are Christine K. Cassel, MD, Thomas W. Chapman, EdD, Daniel P. Garcia, William R. Graber, J. Eugene Grigsby III, PhD, Judith A. Johansen, Kim J. Kaiser, Philip A. Marineau, Jenny J. Ming, Edward Pei, J. Neal Purcell, Cynthia A. Telles, PhD, and Sandra P. Thompkins.

Permanente Medical Groups

The Permanente Medical Groups all have varying organizational structures, but all are headed by a physician executive (called the executive director or executive medical director) who reports to a board of directors made up of the physician-owners of the medical group. The executive director or executive medical director in each region partners with the health plan and hospitals regional president to provide direction to operations in that region. On a national level there is a subordinate entity representing the regional Permanente Medical Groups called the Permanente Federation. Its executive director is John H. Cochran, MD. The Federation is accountable to an Executive Committee, and is made up of four of the nine regional Permanente Medical Group chiefs, along with the executive director of the Permanente Federation. The current Executive Committee is made up of Permanente Federation executive director John H. Cochran, MD, TPMG executive director and CEO Robert Pearl, MD, SCPMG medical director and chairman Jeffrey A. Weisz, MD, TSPMG medical director and chairman Rob Schreiner, MD, and OPMG president and medical director Ronald Copeland, MD. Dr. Copeland also serves as chairman of the Permanente Federation Executive Committee.

History

Early years

Though it has since become the largest organization of its kind, Kaiser was not the first HMO. In its modern form, the HMO combines a large group practice, contracts with employers to care for a group of workers, and a prepayment plan for both hospitals and group practices. The first "contract doctor" system in the West was orchestrated by Dr. Raymond G. Taylor, who created a temporary healthcare system from 1908 to 1912 on behalf of the Los Angeles Board of Public Works to care for the 10,000 workers on the Los Angeles Aqueduct project. The first group prepayment plans appeared in 1929 in response to the onset of the Great Depression. That year, Baylor University started a hospital prepayment plan, the first of several which would ultimately join together to become the Blue Cross insurance network. In Oklahoma, Dr. Michael Shadid recruited local farmers around Elk City, Oklahoma into a small consumer healthcare cooperative. And in Los Angeles, Dr. Donald Ross and Dr. H. Clifford Loos founded the Ross-Loos Clinic to care for City of Los Angeles public utilities workers.

As for Kaiser Permanente, its history dates back to the year 1933 and a tiny hospital in a little town called Desert Center, California. At that time, Kaiser and several other large construction contractors had formed an insurance consortium called Industrial Indemnity to meet their workers' compensation obligations. Garfield had just finished his residency at Los Angeles County-USC Medical Center at a time when jobs were scarce; fortunately, he was able to secure a contract with Industrial Indemnity to care for 5,000 construction workers building the Colorado River Aqueduct in the Mojave Desert. Soon enough, Garfield's new hospital was in a precarious financial state (with mounting debt and the staff of three going unpaid), due in part to Garfield's desire to treat all patients regardless of ability to pay, as well as his insistence on equipping the hospital adequately so that critically injured patients could be stabilized for the long journey to full-service hospitals in Los Angeles.

However, Garfield's dedication and competence won over two Industrial Indemnity executives, Harold Hatch and Alonzo B. Ordway. It was Hatch who proposed to Garfield the specific solution that would lead to the creation of Kaiser Permanente: Industrial Indemnity would prepay 17.5% of premiums, or $1.50 per worker per month, to cover work-related injuries, while the workers would each contribute five cents per day to cover non-work-related injuries. Later, Garfield also credited Ordway with coming up with the general idea of prepayment for industrial healthcare. Garfield also later explained that he did not know much at the time about other similar health plans except for Ross-Loos.

Hatch's solution enabled Garfield to bring his budget back into the positive, and to experiment with providing a broader range of services to the workers besides pure emergency care. By the time work on the aqueduct concluded and the project was wrapped up, Garfield had paid off all his debts, was supervising ten physicians at three hospitals, and controlled a healthy financial reserve of $150,000.

Garfield returned to Los Angeles for further study at County-USC with the intent of entering private practice. However, in March 1938, Consolidated Industries (a consortium led by the Kaiser Company) initiated work on a contract for the upper half of the Grand Coulee Dam in Washington state, and took over responsibility for the thousands of workers who had worked for a different construction consortium on the first half of the dam. Edgar Kaiser, Henry's son, was in charge of the project. To smooth over relations with the workers (who had been badly treated by their earlier employer), Hatch and Ordway persuaded Edgar to meet with Garfield, and in turn Edgar persuaded Garfield to tour the Grand Coulee site. Garfield subsequently agreed to reproduce at Grand Coulee Dam what he had done on the Colorado River Aqueduct project. He immediately spent $100,000 on renovating the decrepit Mason City Hospital and hired seven physicians.

Unlike the workers on Garfield's first project, many workers at Grand Coulee Dam had brought dependents with them. The unions soon forced the Kaiser Company to expand its plan to cover dependents, which resulted in a dramatic shift from industrial medicine into family practice and enabled Garfield to formulate some of the basic principles of Kaiser Permanente. It was also during this time that Henry Kaiser personally became acquainted with Garfield and forged a friendship which lasted until Kaiser's death.

In 1939, the Kaiser Company began working on several huge shipbuilding contracts in Oakland, and by the end of 1941 would control four major shipyards on the West Coast. During 1940, the expansion of the American defense-industrial complex in preparation for entrance into World War II resulted in a massive increase in the number of employees at the Richmond shipyard. In January 1941, Henry Kaiser asked Garfield to set up an insurance plan for the Richmond workers (this was merely contract negotiation with insurance companies), and a year later Kaiser asked Garfield to duplicate at Richmond what he had done at Desert Center and Mason City. Unlike the two other projects, the resulting entity lived on after the construction project that gave birth to it, and it is the direct ancestor of today's Kaiser Permanente.

On March 1, 1942, Sidney R. Garfield & Associates opened its offices in Oakland to provide care to 20,000 workers, followed by the opening of the Permanente Health Plan on June 1. From the beginning, Kaiser Permanente strongly supported preventive medicine and attempted to educate its members about maintaining their own health.

In July the Permanente Foundation was formed to operate Northern California hospitals that would be linked to the outpatient health plans, followed shortly thereafter by the creation of Northern Permanente Foundation for Oregon and Washington and Southern Permanente Foundation for Southern California. The name Permanente came from Permanente Creek, which ran by Henry Kaiser's first cement plant on Black Mountain in Cupertino, California. Kaiser's first wife, Bess Fosburgh, liked the name. The first Permanente Hospital opened in Oakland on August 1. Three weeks later, the Richmond Field Hospital opened, and the Northern Permanente Hospital opened two weeks later to serve workers at the Kaiser shipyard in Vancouver, Washington. In 1944 Kaiser decided to continue the program after the war and to open it up to the general public.

Meanwhile, during the war years, the American Medical Association (AMA) (which opposed managed care organizations from their very beginning) tried to defuse demand for managed care by promoting the rapid expansion of the Blue Cross and Blue Shield preferred provider organization networks.

Courage to Heal, a novel by KP Historical Society President, Paul Bernstein, MD, is based on the story of Garfield's life, his struggles with the AMA, and the origins of Kaiser Permanente.

Postwar growth

The end of World War II brought about a huge plunge in Kaiser Permanente membership; for example, 50,000 workers had left the Northern California yards by July 1945. Membership bottomed out at 17,000 for the entire system but then surged back to 26,000 within six months as Garfield aggressively marketed his plan to the public. Sidney Garfield & Associates had been a sole proprietorship, but in 1948, it was reorganized into a partnership, Permanente Medical Group.

During this period, a substantial amount of growth came from union members; the unions saw Kaiser Permanente care as more affordable and comprehensive than what was available at the time from private physicians under the fee-for-service system. For example, Fortune magazine had reported in 1944 that 90% of the U.S. population could not afford fee-for-service healthcare. Kaiser Permanente membership soared to 154,000 in 1950, 283,000 in 1952, 470,000 in 1954, 556,000 in 1956, and 618,000 in 1958.

From 1944 onward, both Kaiser Permanente and Garfield fought off numerous attacks from the AMA and various state and local medical societies. Fortunately, Henry Kaiser came to the defense of both Garfield and the health plans he had created.

In 1951 the organization acquired its current name when Henry Kaiser unilaterally directed the trustees of the health plans, hospital foundations, and medical groups to add his name before Permanente. However, the physicians in the Permanente Medical Group deeply resented the implication that they were directly controlled by Kaiser, and successfully forced him to back off with respect to their part of the organization. That same year, Kaiser Permanente also began experiments with large-scale multiphasic screening to identify unknown conditions and to facilitate treatment of known ones. Simultaneously, although no one questioned his medical competence, Garfield's deficiencies as an executive were becoming apparent as the organization expanded far beyond his ability to manage it properly.

Even worse, Henry Kaiser became fascinated with the healthcare system created for him by Garfield and began to directly micromanage Kaiser Permanente and Garfield. This resulted in a financial disaster when Kaiser splurged on the new Walnut Creek hospital; his constant intermeddling led to significant friction at every level of the organization. The situation was not helped by Kaiser's marriage to Garfield's head administrative nurse (who had helped care for Kaiser's first wife on her deathbed), convincing Garfield to marry the sister of that nurse, and then having Garfield move in next door to him. Clifford Keene (who would eventually serve as president of Kaiser Permanente) later recalled that this arrangement resulted in a rather dysfunctional and combative family in charge of Kaiser Permanente.

Keene was an experienced Permanente physician whom Garfield had personally hired in 1946. During 1953 he had been trying to get a job at U.S. Steel, but on the morning of December 5, 1953, with internal tensions worsening day by day, Garfield met with Keene at the Mark Hopkins Hotel in San Francisco and asked him to turn around the organization. It took Keene 15 years to realize that Kaiser had forced Garfield to ask Keene to become his replacement. Due to the chaos on the board, Keene at first took control with the vague title of Executive Associate, but it soon became clear to everyone that he was actually in charge and Garfield was to become a lobbyist and "ambassador" for the HMO concept.

However, even with Garfield relieved of day-to-day management duties, the underlying problem of Henry Kaiser's authoritarian management style continued to persist. After several tense confrontations between Kaiser and Permanente Medical Group physicians, the doctors met with Kaiser's top adviser, Eugene Trefethen, at Kaiser's personal estate near Lake Tahoe on July 12, 1955. Trefethen came up with the idea of a contract between the medical groups and the health plans and hospital foundations which would set out roles, responsibilities, and financial distribution.

While Keene and Trefethen struggled to fix the damage from Kaiser's micromanagement and Garfield's ineffectual management, Henry Kaiser moved to Oahu in 1956 and then insisted on expanding Kaiser Permanente into Hawaii in 1958. He promptly ruined what should have been a simple project, and only a last-minute intervention by Keene and Trefethen in August 1960 prevented the total disintegration of the Hawaii organization. By that year, Kaiser membership had grown to 808,000.

Managed care era

Having overseen Kaiser Permanente's successful transformation from Henry Kaiser's healthcare experiment into a large-scale self-sustaining enterprise, Keene retired in 1975. By 1976, membership reached three million. In 1977, all six of Kaiser Permanente's regions had become federally qualified health maintenance organizations. Some believe then-President Richard Nixon specifically had Kaiser Permanente in mind when he signed the Health Maintenance Organization Act of 1973, as the organization was mentioned in an Oval Office discussion of the Act. In 1980, Kaiser acquired a non-profit group practice to create its Mid-Atlantic region, encompassing the District of Columbia, Maryland, and Virginia. In 1985, Kaiser Permanente expanded to Georgia.

Regional evolution

By 1990, Kaiser Permanente provided coverage for about a third of the population of the cities of San Francisco and Oakland; total Northern California membership was over 2.4 million.

Elsewhere, Kaiser Permanente did not do as well, and its geographic footprint changed significantly in the 1990s. The organization spun off or closed outposts in Texas, North Carolina, and the Northeast. In 1998, Kaiser Permanente sold its Texas operations, where reported problems had become so severe that the organization directed its lawyers to attempt to block the release of a Texas Department of Insurance report. This prompted the state attorney general to threaten to revoke the organization's license. In North Carolina, the Industrial Union Department of the AFL-CIO issued a 1996 report critical of the quality of the care the organization provided^{[citation needed]}. Kaiser Permanente closed health plans in Charlotte and Raleigh-Durham in North Carolina four years later. The organization also sold its unprofitable Northeast division in 2000.

In 1995, Kaiser Permanente celebrated its fiftieth anniversary as a public health plan. Two years later, national membership reached nine million. In 1997, the organization established an agreement with the AFL-CIO to explore a new approach to the relationship between management and labor, known as the Labor Management Partnership.

HealthConnect

In 2002, Kaiser Permanente abandoned its attempt to build its own clinical information system with IBM, writing off some $770 million dollars in software assets. This catastrophic information technology failure led to major changes in the organization's approach to digital records. Under George Halvorson's direction, Kaiser looked closely at two medical software vendors, Cerner and Epic Systems, ultimately selecting Epic as the primary vendor for a new system, branded HealthConnect. Although Kaiser's approach shifted to "buy, not build," the project was unprecedented for a civilian system in size and scope. Deployed across all eight Kaiser regions over six years and at a cost of more than $6 billion dollars, it is currently the largest civilian electronic medical record system, serving more than 8.6 million Kaiser Permanente members, implemented at a cost exceeding a half million dollars per physician.

International reputation

Early in the 21st century the NHS and UK department of health became impressed with some aspects of the Kaiser operation, and initiated a series of studies involving several healthcare organisations in England. Visits occurred and suggestions of adopting some KP policies are currently active. The management of hospital bed-occupancy by KP, by means of integrated management in and out of hospital and monitoring progress against care pathways has been admired, and given rise to trials of similar techniques in eight areas of the UK.

In 2005 a controversial British Medical Journal editorial reported a study by California-based academics which compared Kaiser to the British National Health Service. The editorial in the BMJ suggested that KP managed comparable costs to the NHS, but this generated argument mainly that American costs were in fact higher than NHS, and it was generally accepted that the NHS was cheaper and more efficient whereas Kaiser may be more rapid. Feachem's study was subsequently analysed by Talbot-Smith et al., who demonstrated that the Kaiser costs were actually substantially higher than the NHS and for a younger and healthier population.

Marketing

During the 1990s, the organization hired public relations firm Bain and Associates to position their brand in Washington, D.C. The organization also hired Strategic Partnerships LLC to secure^{[citation needed]} tax incentives and a special hearing for government grants.

In 1999, a number of groups successfully sued Kaiser Permanente in regard to its In the Hands of Doctors advertising campaign. The lawsuit revealed that doctors at the organization were not fully in control of decision-making and that there may have been persuasion to limit care with financial bonuses. In 2004, the organization retained Campbell-Ewald to develop a $40-million-dollar ad campaign called Thrive. The campaign, which focuses on the theme of preventive care, was the first since Kaiser Permanente's In the Hands of Doctors campaign. Allison Janney is the company's advertising spokesperson.

Quality of care

In the California Healthcare Quality Report Card 2009 Edition, Kaiser Permanente's Northern California and Southern California regions led the rankings, with each scoring seven out of eight possible stars. Kaiser's rankings in the 2009 Report Card was the first time an HMO has received 4 out of 4 possible stars in Meeting National Standards of Care. Kaiser North and South also received 3 out of 4 stars in How Members Rate their HMO.

U.S. News and World Report, in its 2006 annual ranking of US commercial health plans, ranked Kaiser Foundation Health Plans as follows, out of 246 rated plans:

• 45. Northern California
• 57. Colorado
• 65. Georgia
• 67. Ohio
• 90. Southern California
• 94. Hawaii
• 106. Mid-Atlantic States
• 121. Northwest

A 2004 Consumer Reports survey of planholders ranked Kaiser Permanente overall as average or better. It showed below average ratings in the Colorado and Mid-Atlantic regions for two measures of quality of care: 'care from doctors', and the 'quality of their primary care physician'. The same survey ranked Kaiser Permanente's Northern California region as the best HMO overall among rated plans.

KP's performance has been attributed to three practices: First, KP places a strong emphasis on preventive care, reducing costs later on. Second, its doctors are salaried rather than paid per service, which removes the main incentive for doctors to perform unnecessary procedures. Thirdly, KP attempts to minimize the time patients spend in high-cost hospitals by carefully planning their stay and by shifting care to outpatient clinics. This practice results in lower costs per member, cost savings for KP and greater doctor attention to patients. A comparison to the UK's National Health Service found that patients spend 2-5 times as much time in NHS hospitals as compared to KP hospitals.

Research

Kaiser doctors and others carry out research publishing in peer-reviewed journals and in the organization's own journal Permanente Journal.

Kaiser operates a Division of Research which in 2006 declared around 200 active studies in progress and the Center for Health Research which in 2009 had more than 300 active studies. Kaiser's bias toward prevention is reflected in the areas of interest—vaccine and genetic studies are prominent. The work is funded primarily by federal, state, and other outside (non-Kaiser) institutions.

Measles vaccine project participation

Between June 1990 and October 1991, Kaiser, along with the Los Angeles County Department of Health, Johns Hopkins University and the CDC carried out a clinical trial of the Edmonton strain of Measles vaccine. The Los Angeles arm of the trial involved 1500 (900 receiving the study treatment) mostly black and Latino babies. Other arms ran in Haiti and several African countries. The aim was to induce immunity to Measles earlier, as cases in young children had been causing alarm. The trial was ended early when increased mortality appeared in other countries. Inadequate consent had been obtained, in that parents were not informed that the vaccine, licenced in other countries and registered with the FDA as a trial medication, was unlicensed in the U.S. This raised concerns over US government department ethics, and occasioned an apology by the CDC who ascribed it to an administrative oversight.

Regulation

In California, the Department of Managed Health Care is the state regulatory agency which oversees managed care insurers and providers. In 2005, the Department of Managed Health Care ranked Kaiser Permanente near the top of the list of California managed care insurers, and rated the health plan as superior on preventive care.

Federal regulation of managed care

The organization is mentioned in an Oval Office discussion about the initiation of the Health Maintenance Organization Act of 1973. By 1977, all six of Kaiser's regions had become federally qualified HMOs.

Concerns and violations

As the largest not-for-profit health plan in the United States, Kaiser Permanente is a target of both praise and criticism. In recent years, however, the organization has come under intensive scrutiny for a series of management, patient care, financial, and technology issues, primarily in its Northern and Southern California regions.

Mandatory arbitration

In order to contain costs, Kaiser requires agreement by planholders to submit patient malpractice claims to arbitration rather than litigating through the court system. This has triggered some discussion and dissent. Some cases proceed to court and one argument is over whether the requirement to go through dispute resolution is enforceable^{[citation needed]}.

Kaiser established an Office of Independent Administrators (OIA) in 1999 to oversee the arbitration process. The degree to which this is independent has been questioned.

Wilfredo Engalla is a notable case. In 1991, Engalla died of lung cancer nearly five months after submitting a written demand for arbitration. The California Supreme Court found that Kaiser had a financial incentive to wait until after Engalla died; his spouse could recover $500,000 from Kaiser if the case was arbitrated while he was alive, but only $250,000 after he died. The Foundation for Taxpayer & Consumer Rights contends that Kaiser continues to oppose HMO arbitration reform.

Patients and consumer interest groups sporadically attempt to bring lawsuits against Kaiser Permanente. Recent lawsuits include Gary Rushford's attempt to use proof of a physician lie to overturn an Arbitration decision.

Patient Dumping

Kaiser has settled three cases for alleged patient dumping since 2002. During that same period, the Office of the Inspector General settled 102 cases against US Hospitals which resulted in a monetary payment to the agency.

On November 16, 2006, Los Angeles city officials filed civil and criminal legal action against Kaiser Permanente for "patient dumping"--the delivery of homeless hospitalized patients to other agencies or organizations in order to avoid expensive medical care^{[citation needed]}as reported by National Public Radio's All Things Considered.

The legal filings are intended to punish hospitals for releasing homeless hospital patients (often via taxis) on the sidewalk near relief shelters instead of accepting responsibility for releasing hospital patients into the care of a relative, or of a recognized agency.

The city's decision to charge Kaiser Permanente reportedly was influenced by security camera footage, allegedly showing a 63-year-old patient, dressed in hospital gown and slippers, wandering toward a mission on Skid Row, as outlined in a 20-page complaint. City officials say that as many as 10 other area hospitals are under investigation for possible future action for this practice.

Kidney Transplant Program Violations Lead to Closure

In 2004 Northern California Kaiser Permanente initiated an in-house program for kidney transplantation. Prior to opening the transplant center, Northern California Kaiser patients would generally receive transplants at medical centers associated with the University of California (UC San Francisco and UC Davis). Upon opening the transplant center, Kaiser required that members who are transplant candidates in Northern California obtain services exclusively through its internal KP-owned transplant center.

On May 3, 2006, the Los Angeles Times published an investigative report which showed across-the-board mismanagement in the KP-run transplant program which resulted in delays for patients awaiting kidneys. According to the report, Northern California Kaiser performed 56 transplants in 2005 and twice that many patients died waiting for a kidney. At other California transplant centers, more than twice as many people received kidneys than died during the same period. The practice of delaying these transplants resulted in considerable savings for KP.

On May 13, 2006, after less than two years of operation, Northern California Kaiser announced that it would discontinue the kidney transplant program. As before, Northern California Kaiser now pays for pre-transplant care and transplants at outside hospitals who have proven they are competent in providing this care. This change affected approximately 2,000 patients.

Two patients have filed personal injury lawsuits against Kaiser and the widow of a patient who died has filed a wrongful death claim. According to the lawyer representing the three plaintiffs, more lawsuits are planned.

ABOUT MANAGED CARE PROVIDERS:

The term managed care is used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques") for organizations that use those techniques or provide them as services to other organizations ("managed care organization or MCO"), or to describe systems of financing and delivering health care to enrollees organized around managed care techniques and concepts ("managed care delivery systems"). According to the United States National Library of Medicine, the term "managed care" encompasses programs:

...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.

The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has largely failed in the overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on the quality of U.S. health care delivery.

History

Paul Starr suggests in his analysis of the American health care system (i.e., The Social Transformation of American Medicine) that Richard Nixon was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of HMOs, the first form of managed care.

Managed care plans are widely credited with subduing medical cost inflation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to become more efficient and competitive. Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care. In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997.

The backlash included vocal critics, including disgruntled patients and consumer-advocacy groups, who argued that managed care plans were controlling costs by denying medically necessary services to patients, even in life-threatening situations, or by providing low-quality care. The volume of criticism led many states to pass laws mandating managed-care standards. Complying with these mandates increased costs. Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care networks--according to one analysis, between the years 1970 and 2005 the share of personal health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent[citation required]. So although consumers faced rising health insurance premiums over the period, lower out-of-pocket costs likely [evidence citation required] encouraged consumers to use more health care. Data indicating whether this increase in use was due to voluntary or optional service purchases or the sudden access lower-income citizens had to basic healthcare is not available here at this time.

By the late 1990s, U.S. per capita health care spending began to increase again, peaking around 2002. Despite managed care's mandate to control costs, U.S. healthcare expenditures has continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970.

Nevertheless, according to the trade association America’s Health Insurance Plans, managed care is nearly ubiquitous in the U.S.; 90 percent of insured Americans are now enrolled in plans with some form of managed care. The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts.

Managed care techniques

One of the most characteristic forms of managed care is the use of a panel or network of health care providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following:

• A set of selected providers that furnish a comprehensive array of health care services to enrollees;
• Explicit standards for selecting providers;
• Formal utilization review and quality improvement programs;
• An emphasis on preventive care; and
• Financial incentives to encourage enrollees to use care efficiently.

Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently. A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees. Other managed care techniques include disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity."

Managed care organizations (MCOs)

There is a continuum of organizations that provide managed care, each operating with slightly different business models. Some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. Here is a list of common MCOs:

• Group practice without walls
• Independent practice association
• Management services organization
• Physician practice management company

Types of network-based managed care programs

There are several types of network-based managed care programs. These range from more restrictive to less restrictive, and include:

Health Maintenance Organization (HMO)

Proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy", the HMO concept was promoted by the Nixon Administration as a fix to rising health care costs and set in law as the Health Maintenance Organization Act of 1973. As defined in the act, a federally qualified HMO would in exchange for a subscriber fee (premium) allow members access to a panel of employed physicians or a network of doctors and facilities including hospitals. In return the HMO received mandated market access and could receive federal development funds.

HMOs are licensed at the state level, under a license that is known as a certificate of authority (COA) rather than under an insurance license. In 1972 the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operations. In practice, an HMO is a coordinated delivery system that combines both the financing and delivery of health care for enrollees. In the design of the plan, each member is assigned a "gatekeeper", a primary care physician (PCP) who is responsible for the overall care of members assigned to him/her. Specialty services require a specific referral from the PCP to the specialist. Non-emergency hospital admissions also required specific pre-authorization by the PCP. Typically, services are not covered if performed by a provider not an employee of or specifically approved by the HMO, unless it is an emergency situation as defined by the HMO. Financial sanctions for use of emergency facilities in non-emergent situations were once an issue; however, prudent layperson language now applies to all emergency-service utilization and penalties are rare.

Since the 1980s, under the ERISA Act passed in Congress in 1974 and its preemptive effect on state common law tort lawsuits that "relate to" Employee Benefit Plans, HMOs administering benefits through private employer health plans have been protected by Federal law from malpractice litigation on the grounds that the decisions regarding patient care are administrative rather than medical in nature. See "Cigna v. Calad ", 2004.

Independent Practice Association (IPA)

An Independent Practice Association is a type of HMO that contracts with a group of physicians to provide service to the HMO's members. Most often, the physicians are paid on a basis of capitation, which in this context means a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care. The contract is not usually exclusive, allowing individual doctors or the group to sign contracts with multiple HMOs. Physicians who participate in IPAs usually also serve fee-for-service patients not associated with managed care.

Preferred Provider Organization (PPO)

Rather than contract with the various insurers and third party administrators, providers may contract with preferred provider organizations. A membership allows a substantial discount below their regularly-charged rates from the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor).

In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copay and instead offers a deductible and a coinsurance feature. The deductible represents the first dollar of coverage and is paid by the patient. After the deductible is met, the coinsurance portion applies. If the PPO plan is an 80% coinsurance plan with a $1,000 coinsurance out of pocket, then the patient will pay 100% of the allowed provider fee up to $1,000. After this amount has been paid by the patient, the insurer will pay 80% of subsequent allowed amount and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer and is written off as a discount by the physician.

Because the patient is picking up a substantial portion of the "first dollars" of coverage, PPO are the least expensive types of coverage[1].

Place Of Service (POS)

A POS plan utilizes some of the features of each of the above plans. Members of a POS plan do not make a choice about which system to use until the point at which the service is being used.

In terms of using such a plan, a POS plan has levels of progressively higher patient financial participation as the patient moves away from the more managed features of the plan. For example, if the patient stays in a network of providers and seeks a referral to use a specialist, they may have a copayment only. However, if they use an out of network provider, but do not seek a referral, they will pay more, and so on.

Managed care in indemnity insurance plans

Many "traditional" or "indemnity" health insurance plans now incorporate some managed care features such as precertification for non-emergency hospital admissions and utilization reviews. These are sometimes described as "managed indemnity" plans.

Impacts

The overall impact of managed care remains widely debated. Proponents argue that it has increased efficiency, improved overall standards, and led to a better understanding of the relationship between costs and quality. They argue that there is no consistent, direct correlation between the cost of care and its quality, pointing to a 2002 Juran Institute study which estimated that the "cost of poor quality" caused by overuse, misuse, and waste amounts to 30 percent of all direct health care spending. The emerging practice of evidence-based medicine is being used to determine when lower-cost medicine may in fact be more effective.

Critics of managed care argue that "for-profit" managed care has been an unsuccessful health policy, as it has contributed to higher health care costs (25-33% higher overhead at some of the largest HMOs), increased the number of uninsured citizens, driven away health care providers, and applied downward pressure on quality (worse scores on 14 of 14 quality indicators reported to the National Committee for Quality Assurance).

The most common managed care financial arrangement, capitation, places health care providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Unfortunately, large health insurers manage such risks better, in the sense of predictable costs, than small insurers. Small insurers, like individual consumers, tend to have annual costs that fluctuate far more than larger insurers. The term "Professional Caregiver Insurance Risk explains the inefficiencies in health care finance that result when insurance risks are inefficiently transferred to health care providers who are expected to cover such costs in return for their capitation payments. As Cox (2006) demonstrates, providers cannot be adequately compensated for their insurance risks without forcing managed care organizations to become price uncompetitive vis-a-vis risk retaining insurers.

Health insurance plan with the same features as traditional indemnity coverage except for limited implementation of cost containment or managed care concepts.

ABOUT HEALTH INSURANCE:

Health insurance is insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government.

By estimating the overall risk of healthcare expenses, a routine finance structure (such as a monthly premium or annual tax) can be developed, ensuring that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.

History and evolution

The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance.

Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the U.S. by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, the origins of sickness coverage in the U.S. effectively date from 1890. The first employer-sponsored group disability policy was issued in 1911.

Before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and most prescription drugs, but this was not always the case.

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II.

How it works

A health insurance policy is a contract between an insurance company and an individual or his sponsor (e.g. an employer). The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract or "Evidence of Coverage" booklet. The individual insured person's obligations may take several forms:

• Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan each month to purchase health coverage.
• Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care.
• Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.
• Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of a surgery over and above a co-payment, while the insurance company pays the other 80%. If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain.
• Exclusions: Not all services are covered. The insured person is generally expected to pay the full cost of non-covered services out of their own pocket.
• Coverage limits: Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
• Out-of-pocket maximums: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and the health company pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
• Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.
• In-Network Provider: (U.S. term) A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers.
• Prior Authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.
• Explanation of Benefits: A document sent by an insurer to a patient explaining what was covered for a medical service, and how they arrived at the payment amount and patient responsibility amount.

Prescription drug plans are a form of insurance offered through some employer benefit plans in the U.S., where the patient pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan.

Some, if not most, health care providers in the United States will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay. The insurance company pays out of network providers according to "reasonable and customary" charges, which may be less than the provider's usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider's standard charges. It generally costs the patient less to use an in-network provider.

Health plan vs. health insurance

Historically, HMOs tended to use the term "health plan", while commercial insurance companies used the term "health insurance". A health plan can also refer to a subscription-based medical care arrangement offered through HMOs, preferred provider organizations, or point of service plans. These plans are similar to pre-paid dental, pre-paid legal, and pre-paid vision plans. Pre-paid health plans typically pay for a fixed number of services (for instance, $300 in preventive care, a certain number of days of hospice care or care in a skilled nursing facility, a fixed number of home health visits, a fixed number of spinal manipulation charges, etc.) The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (concurrent utilization review).

Comprehensive vs. scheduled

Comprehensive health insurance pays a percentage of the cost of hospital and physician charges after a deductible (usually applies to hospital charges) or a co-pay (usually applies to physician charges, but may apply to some hospital services) is met by the insured. These plans are generally expensive because of the high potential benefit payout — $1,000,000 to 5,000,000 is common — and because of the vast array of covered benefits.

Scheduled health insurance plans are not meant to replace a traditional comprehensive health insurance plans and are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug. In recent years, these plans have taken the name mini-med plans or association plans. The term "association" is often used to describe them because they require membership in an association that must exist for some other purpose than to sell insurance. Examples include the National Association for the Self Employed and the Health Care Credit Union Association. These plans may provide benefits for hospitalization and surgical, but these benefits will be limited. Scheduled plans are not meant to be effective for catastrophic events. These plans cost much less than comprehensive health insurance. They generally pay limited benefits amounts directly to the service provider, and payments are based upon the plan's "schedule of benefits". Annual benefits maximums for a typical scheduled health insurance plan may range from $1,000 to $25,000.

Other factors affecting insurance prices

A recent study by PriceWaterhouseCoopers examining the drivers of rising health care costs in the U.S. pointed to increased utilization created by increased consumer demand, new treatments, and more intensive diagnostic testing, as the most significant driver. People in developed countries are living longer. The population of those countries is aging, and a larger group of senior citizens requires more intensive medical care than a young healthier population. Advances in medicine and medical technology can also increase the cost of medical treatment. Lifestyle-related factors can increase utilization and therefore insurance prices, such as: increases in obesity caused by insufficient exercise and unhealthy food choices; excessive alcohol use, smoking, and use of street drugs. Other factors noted by the PWC study included the movement to broader-access plans, higher-priced technologies, and cost-shifting from Medicaid and the uninsured to private payers.

United States

The United States health care system relies heavily on private health insurance, which is the primary source of coverage for most Americans. According to the CDC, approximately 58% of Americans have private health insurance. Unfortunately these insurance companies utilize a pre-existing exemption clause in order to control costs and maximize profit. A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance. Together with the fact that in just three years, the Medicare and Medicaid programs will account for 50 percent of all national health spending., has fueled an outcry for an overhaul of the health care system in the United States. The House of Representatives passed a sweeping health care bill by a vote of 220-215 on November 7, 2009. Currently the fate of the bill rests on the Senate. The legislation includes changes that would prevent private insurance companies from the using pre-existing condition clause, additionally it would give the government the power to negotiate policy premiums for those who opt to participate in the public option.

Public programs provide the primary source of coverage for most seniors citizens and for low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors and certain disabled individuals, Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families, and SCHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.

A few states have taken serious steps toward universal health care coverage, most notably Minnesota, Massachusetts and Connecticut, with recent examples being the Massachusetts 2006 Health Reform Statute and Connecticut's SustiNet plan to provide quality, affordable health care to state residents.

In 2006, there were 47 million people in the United States (16% of the population) who were without health insurance for at least part of that year. About 37% of the uninsured live in households with an income over $50,000. Even those with insurance may not be adequately covered, as insurers often deny claims, leaving policy holders with limited short-term recourse. As bioethicist Jacob M. Appel has argued, "Having health insurance does not do you any good if that insurance doesn't cover your illness or injury."

In 2004, U.S. health insurers directly employed almost 470,000 people at an average salary of $61,409. (As of the fourth quarter of 2007, the total U.S. labor force stood at 153.6 million, of whom 146.3 million were employed. Employment related to all forms of insurance totaled 2.3 million. Mean annual earnings for full-time civilian workers as of June 2006 were $41,231; median earnings were $33,634.) The insurance industry also represents a significant lobbying group in the United States. For 2008 insurance was the 8th among industries in political contributions to members of Congress, giving $28,654,121, of which 51% was given to Democrats and 49% to Republicans, with the top recipient of insurance industry contributions being Senator John McCain (R-AZ). The leading contributor from the insurance industry — as measured by total political contributions — was AFLAC, Inc., which contributed $907,150 in 2007.

The US health care system has been provided by private insurance & finance, which is creating exclusion from the system for many citizens. The poor portion of the population is being victimized the most intensively; as a result, government policies have passed to provide public health care for the people who are most in need ( children, seniors, and the poor individuals).

California Health Insurance

In 2007, 87% of Californians had some form of health insurance. Services in California range from private offerings: HMOs, PPOs to public programs: Medi-Cal, Medicare, and Healthy Families (SCHIP).

At times, it is difficult to navigate the complex health insurance system. California developed a solution to assist people across the State and is one of the only States to have an Office devoted to giving people tips and resources to get the best care possible. California's Office of the Patient Advocate was established July 2000 to publish a yearly Health Care Quality Report Card on the Top HMOs, PPOs, and Medical Groups and to create and distribute helpful tips and resources to give Californians the tools needed to get the best care.

Additionally, California has a Help Center that assists Californians when they have problems with their health insurance. The Help Center is run by the Department of Managed Health Care, the government department that oversees and regulates HMOs and some PPOs. The number to call is 1.888.466.2219, they have staff on hand to help you through the process of filing a complaint, or just figuring out what to do next.