One of our colleagues explains why leaving Kaiser Permanente was the right career move for her.
I made a career change most ophthalmologists don’t even consider: I resigned from Kaiser voluntarily after making partner/shareholder. In an era where solo practitioners are trying to join a bigger organization and new graduates drool over a Kaiser offer, I have found that the “Kaiser way” may not be the “right way.”
I first joined the Permanente Medical Group fresh out of training and thought how lucky I was to have landed such a coveted position. Conventional beliefs have it that the Kaiser salary (plus benefits) was significantly higher than what one would be make in private practice or in academia. Also, I wouldn’t have to work unethically to sell premium lenses or knock on doors for patient referrals.
While some of these advantages (such as patient referrals) still hold true and are the reasons for Kaiser’s attractiveness to some candidates, let me share some Kaiser “secrets” to provide a clearer depiction of the organization so that one can make an informed career decision.
For those who are not familiar with the Kaiser system, here is a very abbreviated explanation. Kaiser Permanente is an HMO, and consists of the Kaiser Foundation Health Plan (the Kaiser insurance) and the Permanente Medical Groups (the Kaiser doctors). The patients buy the Kaiser insurance and they are only allowed to see Kaiser doctors. The Kaiser doctors are salaried from the pool of insurance premiums and provide service only to the Kaiser patients. In the Kaiser model, services are prepaid, so there is no financial incentive or penalty to providing or receiving medical care.
The first myth I’d like to debunk is “Kaiser’s starting salary is significantly higher than one would make in private practice.” The way Kaiser sets its salary is that we take the Medscape survey median and add a preset boost. So for ophthalmology, the Medscape median is 180K, then depending on your region, an additional +/-100K gives an entry-level salary of ~280K for a 1.0 FTE (full-time employee). This seems substantial to a debt-ridden resident, but one may not understand two key flaws in this number. First of all, the Medscape salary survey is not accurate: it is self-reported and it lumps everyone together, so that 180K is very low for a full-time ophthalmologist. Second, private practice is performance-based, so the more patients you see, the more you will make. Kaiser makes everyone see a certain number of patients with 30-40% new consults and 60-70% follow-ups. A Kaiser ophthalmologist could make around 500K in private practice if s/he sees the same number of patients with the same new-to-follow-up ratio. So Kaiser is actually paying their ophthalmologists 40% less than what they should make. And Kaiser does not allow for negotiation of compensation.
The biggest gripe I’ve heard as a chief and experienced as a Kaiser physician is the lack of flexibility or the lack of autonomy. Clinic, OR, and call schedules are made 6-months in advance. The clinic template is also preset. If you want to start clinic a little bit later, that’s not possible. If you want to leave clinic a little bit earlier, that’s not possible. If you don’t want to take an hour for lunch, that’s not possible. If you don’t want to work a full FTE but your center needs you to work a full FTE, that’s not possible. This rigidity may seem ridiculous but it is what all Kaiser physicians live by.
The metrics by which a Kaiser physician is evaluated against are somewhat unintuitive. This is because all specialties use the same metrics, be it ophthalmology or neurology or neurosurgery. One such metric is a patient satisfaction score (MPS score). This number comes from a patient satisfaction survey in which only 5 questions out of a 25-question survey pertains to physician performance. We all know that surveys are prone to survey bias, but Kaiser uses this MPS score as a physician performance score. Another guideline is “same-day/next-day access”, meaning that a patient requesting a referral is seen the same day or the next day. This immediate access may make sense for medical subspecialties or general surgery. but for ophthalmology or optometry, it makes little sense. Having a cataract evaluation tomorrow is not as important as having a cataract evaluation next Wednesday when you have time off of work to go see the ophthalmologist. But in this example, the physician gets a negative point for tailoring to the patient's preference versus forcing the patient to take the same-day or next-day slot. To be an all-star Kaiser physician, one simply needs to meet the “same-day/next-day” access and perform the blood pressure/flu shot/colon cancer screening (yes, all ophthalmologists have to give patients the stool occult kit).
I often jokingly compare the Kaiser environment to socialism to my non-Kaiser friends. There is some truth to this. Although Kaiser does not push its providers to sell premium lenses or perform costly procedures, there is also no incentive to perform. One can be a mediocre physician and get the same salary as an overachieving physician, so there is less motivation to do more than mediocre. Just as one cannot negotiate the salary, incentive pay and annual increases are also predetermined with no room for negotiation. Lastly, remember that in the Kaiser model, services are prepaid, so there is no financial incentive to provide medial care. In fact, there is incentive to providing less medical care, because the less care Kaiser gives, the more money Kaiser keeps. While each visit in private practice generates revenue, each non-visit at Kaiser generates revenue. So for a condition such as POAG that may generate 3-4 visits annually to the ophthalmologist in private practice, at Kaiser, it is compressed into 1-2 visits.
There are many physicians who fit the Kaiser model and are happy working for Kaiser. For the newly minted residents and fellows who are wondering if the “Kaiser way” is “the way,” understand that the “Kaiser way” is not “the right way” or “the only way.” When you are considering your options, don’t be too envious of your Kaiser friends, and don’t assume private practice is “the wrong way." You have to find what’s the best fit for your personality and your lifestyle and desires. This article is simply here to provide you with additional information about Kaiser to help you make that decision.
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