Dr. Jeffrey Weisz Has Big Plans for Kaiser Permanente

He not only foresees membership growth, but plans to reduce outside referrals to OHSU and consider the role of nurse practitioners and physician assistants

February 22, 2012 – Dr. Jeffrey Weisz is a man on a mission. As the newly appointed president and executive medical director for the Northwest Permanente Medical Group, he’s setting his sights high.

“I believe Kaiser is the answer to healthcare in America, and I’m going to prove it,” he said in a candid interview with The Lund Report. “We’re going to save more lives, and out perform everyone with better service and access, and have the best price and the best quality. Insurance companies that have the best rates win the market. But, I want the best rate and the best quality.”

Competitors such as Providence want Kaiser’s 500,000 members, he said. “But they’re not getting them. We have a better chance they’ll lose them to us because I’m very laser focused on what needs to be done. I want to take over the market and make Kaiser as big as I can, and would like to add 20-25,000 new members every year.”

Weisz intends to partner with private employers interested in lowering their healthcare costs and having a healthier work force.

“We can run a report that no one else can, and tell employers how many of their employees smoke, how many are overweight, how many of people with diabetes have their blood sugar out of control,” he said. “No one else can do this. Everyone’s looking for an answer on how to lower healthcare costs that are escalating every year. If you prevent illness and have higher quality, you’re going to lower your costs and save lives. That’s what I believe in and what I’ll help bring to the northwest region.”

Weisz has other changes in mind as well since joining Kaiser on January 1.

Reducing Outside Medical Costs

Up until now Kaiser members have also been able to see physicians at Oregon Health & Science University. But that’s about to change. Unless OHSU can provide care not available at Kaiser such as heart transplants and complicated pediatric treatments, its members will have to pay the bill if they decide to be seen at OHSU.

“OHSU has a great training program and 60 percent of our doctors are trained there, and we’re spending millions of dollars in care at OHSU,” he said. “Up until now, it’s been a fairly easy path to go over there. I believe we have the same quality care.

Once its new hospital opens in western Washington County next year, Kaiser will have a robot in place, at a cost of several million dollars, and will no longer need to hospitalize patients at Providence St. Vincent Medical Center. Currently, it uses 30 of its beds nearly every day.

“We believe we can do better with our own patients at our own hospital,” he said. “When the robot was introduced, virtually every hospital – other than Kaiser Sunnyside – bought a robot immediately because they wanted to put more patients in their beds.”

Urologists believe the robot gives them better surgical techniques and fewer adverse complications with nerve injuries so people having surgery for prostate cancer can still have normal sexual function and fewer continence problems.

“Most young urologists doing prostate cancer surgery are trained on the robot, and if you don’t have one, they don’t want to join your organization,” he said. “Medicine has become big business and there’s a subset of patients and everyone is competing for the same group. When any new technology comes in, we do an evidence based analysis to make sure we should buy this new technology. If there’s no evidence we won’t buy it. We didn’t buy the robot earlier because were waiting for more literature and more data to see that it was evidence based. We want to be careful because we’re spending our members’ money.”

Niche Care for Nurse Practitioners and Physician Assistants

On a philosophical level, Weisz believes nurse practitioners and physician assistants are better at niche care – becoming an expert in one or several diseases. “Don’t forget I went to medical school, and it’s complicated to take care of patients,” he said.

Nurse practitioners could manage a panel of diabetics, chronic congestive heart failure or well baby visits. Now they usually take care of everything a patient may need.

“I’m going to try and focus them more on niche care,” he said. And, if nurse practitioners and physician assistants need more training diabetes, physicians can teach them.

Weisz realizes everyone might not appreciate this new focus and developed a similar approach while working in southern California. “Anytime you change anything in healthcare people are always upset. But, you have to do what’s right for the patient. It’s very hard for a doctor to assess a patient and they went to medical school for four years. If someone comes in with acute abdominal pain, it’s a complicated thing. Can they feel the spleen, feel the liver, do they know what tests to order? It’s hard for doctors to figure out and even harder for people who haven’t gone to medical school.”

When asked to clarify this statement, Richard Odell, director of communications and assistant to the president, provided the following response to The Lund Report:

“Dr. Weisz is not talking about creating a separate structure for these professionals.  In fact, just the opposite embedding them in a specific area of practice where they would work along side physicians.

“For example, there is significant value in using highly skilled NP's and PA's (rather than have them managing a panel of primary care patients) and having them focus on a very specific area of practice.

“These areas of practice could include case and disease management in coordinating care across multiple areas of the care delivery system.  It could also include placing them into certain high volume specialized procedural based care settings; for example in a gastroenterology practice performing colonoscopies; or in a head/neck surgery practice to perform myringotomies (placing tubes in children's ears for middle ear infections).  There are many other examples.

“Finally, under the current way in which Kaiser Permanente care delivery operates, NWP is responsible for the practice of NPs, PAs and mental health therapists;  but they report to the Health Plan and not NWP.

“I don't believe that Dr. Weisz was talking about creating a separate structure for the work that nurses and other clinicians do. He was talking about how an RN often becomes quite adept in a certain area of care, that might be called a 'niche.' A good example of that would be the case managers for congestive heart failure patients. Much of that care is coordinated and delivered by non physicians, in a team care or medical home type of model, but the physicians is still the leader of that team when it comes to making key clinical decisions. “

Weisz’ Has a Track Record in Southern California

Before joining Kaiser Northwest, Weisz, was executive medical director and chairman of the board of the Southern California Permanente Medical Group, a position he held since 2004.

Early on, he decided Kaiser would become number one in prevention in America. Shortly after joining Kaiser, he had attended a national Kaiser meeting in Oakland on breast cancer quality screening and learned that Kaiser’s rate was in the 70th percentile.

“I got up and said those rates aren’t high enough, and I don’t want to go to a meeting where the rates are mediocre,” he said. “In just one year we got all 12 medical centers over 80 percent.”

Two years later, Kaiser became number one in America, having screened more than 90 percent of women between the ages of 50-65 for breast cancer.

“The reason that’s important is because breast cancer is the number one issue women think about and if pick up breast cancer in the early stage, you can do minimal surgery and don’t have to do radiation and chemotherapy or reconstructive surgery, and you have a better chance of saving lives.”

Soon the success in breast screening caught fire in southern California and Weisz realized similar spikes in other healthy measures – from 2004 through 2010, cholesterol control rose by 22.5 percent; blood pressure control, 41.8 percent, smoking cessation decreased by 17 percent; cervical cancer screening went up 5.8 percent and colon cancer screening, by 29.8 percent.

“By picking up the disease early, you prevent less advanced disease and spend less money on chemotherapy and you can put that money back in your system so you can have lower healthcare rates,” said Weisz who intends to create similar screening goals for the Pacific Northwest.

There’s no reason, he said, anyone over age 50, should die of colon cancer if polyps can be identified earlier by investing in colonoscopies. “We’re spending millions of dollars on chemo for advanced disease – why not pick it up early?” he said.

With Kaiser’s sophisticated electronic healthcare system, specialists and primary care doctors can determine whether a patient has undergone screening for colon or breast cancer, for example.

“Anytime one of our patient’s goes to a doctor – be it an allergist or dermatologist, they’ll take your blood pressure and start you on screening tools. That’s how you improve quality and increase prevention,” he said,

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Excellent. Having briefly met him I am excited by the opportunity to have Dr. Weisz's vision and energy in our market. There is no room for complacency or self-serving status quo and I hope his vision inspires others to be better, do more. PR

Kaiser needs to start work to increase their network of providers if they want more members. Members are starting to have problems assigning a new primary care physician when their primary care doctor leaves. Seeing a NP or PA is acceptable for some services, but members are not going to be happy having a NP or PA as their primary care provider. Issues with a lack of providers is going to trickle down to issues with access to care.

I agree. As a healthy Kaiser member and a health care practitioner, I have only had to use my insurance occasionally, but it can be difficult to get in even when you know the system. Where are the digital x-ray machines in their dental offices that everyone else seems to have? Where are the appointments with specialists when you need to see one yesterday, not next month?

Dr. Weisz seems to misunderstand the training of nurse practitioners as analagous to physician assistants. Nurse practitioners are educationally prepared in community based primary care which focuses on primary care of populations: peds, family practice, adult health, or mental health. They are not "niche" providers and are not sub specialists. Nor do they "learn" subspecialization from physicians--there are individual nursing specific pathways such as national certification, residencies, fellowships and options besides OJT. NPs at Kaiser should be providing primary care services. His effort to reorganize them to work under physicians in subspecialty practice shows a misunderstanding of both the professional competencies and the state law and scope of practice for Oregon.

Clearly Dr Weisz does not know the Nurse Practice Act in Oregon where NPs have practiced independently for decades. In California NPs are not allowed completely independent practice and cannot prescribe independently, thus he has a misconception of what NPs can do based on his past experience. Additionally most new NPs are doctorally prepared DNPs and many practicing NPs are returning to school to complete their doctorate to provide better care in a complex health care system. The additional education isnt about clinical management but involves leadership, transformational change theory and practice improvement. Dr Weisz should embrace these DNPs to meet his goals for the region, as most MDs are not educated in change or practice improvement and will need to be educated by someone. Maybe this is the "niche" for the NP, to teach the MDs. That said, I practice at Kaiser as an NP with a wonderful team of MDs, PAs and NPs all working together to provide high quality care. It would be sad to see patients and yes, or MD colleagues suffer due to Dr Weisz's lack of understanding in the NW.

"Its members will have to pay the bill if they decide to be seen at OHSU". Thank God I have dual coverage. I'm about to undergo treatment that I was referred to OHSU for because they are the best in the state regarding this treatment. I refuse to let some man, who doesn't even have a license to practice medicine in the state of Oregon, decide that my life is not worth the money for excellent care, but rather keep me in the Kaiser system to save a few bucks. I may have to re-think my coverage and I know my company will support this as well. Too bad. Kaiser could have been the "Go-To" HMO............but it sounds like it could be the one we run from.

I agree with this comment...I have dual coverage as well but thought I would test ride the Kaiser system. Very impressed with the technology and abiltiy to see lab results, schedule appointments, etc. And was very impressed many years back when Kaiser realized that they were not specialist in many areas (cardiac for example) and use St Vincent. And Kaiser also has other contracts with other specialty organizations. I think there will be an mass exodus of many members if they take these specialized facilities away. If that is one think Kaiser is not recognized for, it is speciality services. They are excellent in primary care and health management.

Oh, great; Kaiser sets up more barriers to better care: Their way or the highway. What about access to clinical trials at OHSU? What about participation in collaboratives, which Kaiser mostly shuns? (CUSP/CLABSI being a prime example) Kaiser leaders believe EHRs are both necessary and sufficient for great care. Necessary, probably. Sufficient, no. Kaiser saves money by denying care, or making it difficult to access. (Do NOT have anything go wrong on a weekend, especially if you live on the west side!) If you want a flu shot, great. If you get pneumonia, good luck. (And Kaiser makes its stats look good by 'sampling' rather than actual reporting.) A young friend calls Kaiser "the McDonald's of health care." She's spot-on.

Does Dr. Weisz plan to move all midlevel providers (PAs, NPs) out of primary care, and then try to meet the needs of the physicians who are left in the practice? Probably. That's what he did in southern California. Is this a realistic long-term strategy? I don't think so. How will he recruit enough physicians to make this sustainable? Look at the trends in the US, where primary care residency programs (internal and family medicine) often can't fill their slots; and no wonder, with less pay than the specialties, and increasingly heavy workloads in primary care. Many primary care providers are working part-time just to survive, or take work home nights and weekends to stay caught up. Across the US, midlevel providers are being utilized for their skills and training in diagnosis and treatment, often helping "fill the gap" left by the lack of primary care physicians. And studies have shown that PAs and NPs provide quality care, not second-rate care. The strength of the group practice approach at Kaiser is that all providers can confer with their colleagues on more complicated cases, physician and midlevel providers both. Bravo to the commenter above who discusses the training of NPs in primary care. According to the 2010 AAPA census, 31% of PAs work in primary care. The broad-based training for Physician Assistants does permit some flexibility in work environments, but a large majority choose to work in primary care (more than any other "specialty") because that is where they are needed, and where they can develop a longitudinal relationship with their patients. http://www.aapa.org/uploadedFiles/content/Research/2010%20Census%20Repor... If you are a Kaiser member and would hate to lose your primary care PA or NP, I encourage you to write a letter of protest to Dr. Weisz!

I see Dr. Weisz's vision refreshing and needed. Keeping people healthly by emphasizing prevention is key and is what Kaiser Permanente is all about. There are hurdles in every system and no system is perfect. It is obvious the model Kaiser Permanente invented is the right way to go as evidenced by the market beginning to look more and more like them.

Dear Kaiser members - Please vote with your dollars and come to health insurers that let you make the decision where, when and by whom you'd like to be treated rather than experimenting on how to save more $$ at the expense of you well-being.

I cannot agree more with all the comments re Dr Weisz understanding of advanced practice nurses such as NPs,CNSs, CRNAs. and CNMs. He lacks understanding of scope of practice as well as academic and post graduate education. He also does not seem to understand the quality of care provided by NPs as well as our PA-C colleagues. KHP NW has had a long standing tradition of utilzing these clinicians in primary care. In addition data is overwhelmingly clear that NPs & PA-Cs provide high quality health care at lower cost.

Article appears abbreviated considering this is a discussion with the physician leader who guided teams which provided the highest quality care at market defining rates for 3.4 million patients in Southern California. NW Permanente has never been the most respected or top performing Permanente group. NW Permanente only had to beat the local competitors which was not difficult. The Northwest is at least 5-10 years behind healthcare leaders. Glad to have reason to believe forces are in place to reverse the trend. Have others seen their health insurance premiums triple in that past 10-15 years while their quality has remain unchanged and customer service declined dramatically? After experiencing care in other countries and at a Kaiser facility with Permanente physicians in California, I'm appalled at the state of affairs in Oregon. Family, friends, and quality of life keep me coming back to Oregon. Finally my employer will be offering Kaiser as an option because they realized how unhappy employees were with the non-Kaiser options.

I find Dr. Weisz refreshing and what he will bring to the Northwest region of Kaiser Permanente will be fantastic. Kaiser Permanente's focus on prevention is exactly what our country needs. Sure there are quirks to every system, no system is perfect. But from what I can tell, Kaiser Permanente's competitors are trying to look more like them. Does that tell you anything about there model of care and quality of care?

I wonder if Dr. Weisz got pushed out of Southern California Permanente Medical Group for supporting doctors who concealed urology X-rays. My doctors claimed that a large number of X-rays had been taken of me on June 15, 2011 at Garfield Specialty Center in San Diego (which boasts that all X-rays are digitized), but that only a tiny fraction of my X-rays had been saved--on thermal paper! Also, Dr. Weisz supported the falsification of a report about the X-rays. Maura Larkins

Kaiser has a long-and unfortunate history- of offering no inpatient care to individuals with persist mental illness. They are sent elsewhere. Is Dr. Weisze going to change this? Michael Kaplan

Kaiser actually now has their own mental health and addiction inpatient facility, I have a family member that stayed there for a week and was very happy with the care and staff. It's been open for last 2-3 years, before Dr. Weisze

I feel that Kaiser has a long way to go. My husband was almost killed by the ER staff. They made some serious mistakes that almost caused his demise. After several months of refusing to be held responsible, Kaiser finally apologized. We asked that all direct expenses we had made to correct their mistake be refunded, we were given the "run around" and they now refuse to correct their mistake. If we had made a mistake, we would have been held financially responsible. My faith and trust in Kaiser has been taken from me. My husband has been left with major problems, a direct result of their mistake. ER!)! states that you CLEAN THE WOUND. How basic is that?

I've been a RN for nearly 40 years. My career has been rich in experience across a wide variety of hospital and community settings both as a staff nurse and a nurse manager. As a health care consumer I've experienced health care from NPs, PAs and/or Physicians. I have received wonderful care and treatment from all of them whether in small medical clinics to vast systems such as Kaiser Permanente. Each time I've had the opportunity to choose Kaiser Permanente for both my health insurance and system of health care, KP has been my first choice. I have received primary health care as well as excellent care for specific serious health problems. It is my impression that now with electronic medical records, my care has improved because of the coordination that can occur across services. In addition, it is obvious to me that KP is constantly in the process of advancing and improving care and service delivery. No system is perfect and they all experience hiccups now and then. Overall, compared to other health plans and services delivery I've personally experienced, I find KP to be a much better option than most others available in the Portland area. We shall have to wait and see how much of Dr. Weisz's ideas and plans actually get implemented. Some of the ideas of his mentioned in the article make sense to me. However, like a couple of other commentators, I'm a bit leery about the possibility of pulling NPs and PAs from the delivery of primary care in order for them to provide "niche care"

Dr Weisz failed to present a scintilla of data or a single scientific source for his assertion that PAs and NPs are better qualified in "niche practices" than primary care. Kaiser itself has 40 years of history of successful evidenced based practice of PAs and NPs in primary care. His assertion is totally without merit.

PA's are trained in the MEDICAL model. JUST LIKE DOCTORS. We train for at least 2 yrs post bachelor's degree along side medical students. Yes, Dr Weisz, we do know how to feel a spleen and a liver and how to order tests and interpret them, as well as many other things. I frequently have physicians coming to me for advice. Likewise, I utilize my supervising doctors if I have ANY QUESTIONS. Of note, since coming to Kaiser 2 yrs ago, my lil' ol' PA exams have picked up on TWO cancers MISSED BY physicians and their more cursory exams. Please learn more about the profession and working PA/ physician relationships before throwing us into a paradigm that will under utilize our skill and knowledge. PA supervision is important, but to pigeon hole us into doing work that can be accomplished by RN's and OR techs is big mistake. USE US! We can offer our members good solid medical care at a lower cost and can improve the working lives of our physician colleagues when used appropriately. Dr. Weisz you have some really great ideas, but this one about putting some of your NP/PA colleagues into niche positions and ditching the rest is a BIG, BIG ERROR.

I am simultaneously in agreement with some issues on the importance of health care measures and appalled at Dr. Weisz's comments. Prevention is a monumental task in health care and Kaiser has been very successful. Every patient and provider should be very proud of the work being done at KP.org. Dr. Weisz's does not seem to acknowledge that many of these goals of prevention have been achieved by the incredible work of the Nurse Practitioner's and PA's working in Primary Care along with the MD's, DO's, RN's , MA's, secretaries, managers, support staff, managers and employees of this organization. As the head of a health care organization it is unconscionable to me that he is unaware of the education and training of the nurse practitioner or PA that see so many of the patient's this organization serves. The same providers that have worked hard for years to achieve the goals of the organization, carry large percentages of the healthcare population and have done so with great statistics and outcomes. All available and easily supported using the EMR that Dr. Weisz refers to in this article. Nurse Practitioners and PA's do not want to replace, nor do they disavow the education and training of the Family Practice Physician. It is a shame however that many physicians are not making themselves aware of the training and education of those colleges that work alongside them. I am also greatly dismayed that Dr. Weisz offers no statistics or data to back up his theory on "niche care". The AMA has been reviewing the research for years concerning the practice differences between NP's and MD's in Family Practice and the research speaks for itself. The January 20, 2011 New England Journal of Medicine (NEJM); "Perspective: Broadening the Scope of Nursing Practice , and the AAFP, American Academy of Family Practice; October, 1998; Nurse Practitioners ;Growing competition for Family Physicians; JAMA; - Vol 283. No1, January 5, 2000 : all speak to the fact that "no significant difference can be found in the outcomes or the practice when compared between NP's and Family Practice MD's. These are just a few of the articles that also site many others to vie a perspective over the years. Also - Medicare and Medicaid reimburses at 100% for NP's as the Federal Government has also conducted many studies and found the care comparable. I would hope the physicians that have worked side by side with their colleges that are Nurse Practitioners and PA's would stand up and support their colleges . I would also hope that Dr. Weisz would read the practice act for Nurse Practitioners and realize the NP's are not "AC's (Associated Clinicians) but Independent Providers in 20 States that practice within the guidelines of their license and Board Certification. Yes, they are actually "Board Certified" in their area of specialty be it Pediatrics, Adult, Family, Mental Health, etc. They are proud to provide care for the many incredible patients in the Kaiser System. I have never heard an NP state they want to be a physician but instead take great pride in the training and the nursing model they bring to the health care team. NP's do not wish to replace or take over the role of the MD but instead wish only to bring quality care to the patients they serve and utilize the education, expertise, clinical training and years of practice to the full capability of their licensure and board certification. Thank You, Sincerely and Respectfully, Janie Swift, ARNP, FNP-C

I wish you were correct in your statement, "NP's do not wish to replace or take over the role of the MD ..." However, as as been posted in the comments section on the Lund Report articles on HB 4010 articles, some NPs very much see themselves as at least the replacement of the MD if not "smarter." And I quote from these comments: "What is not told is that NPs really have as much education and training as MDs ... After the new grad MD and the new grad NP have been OTJ their skills are equal in primary care--at least equal. The NP may actually have more skill due to the past experience as a nurse--surely this experience more than equates whatever experience the MD got in medical school training. The fact that the NP can do what the MD does is all that should matter in primary care ... Do not punish the NP for being smarter and paying less for their education. We should be rewarding that." The absurdity of these comments are self evident. But the fact that some NPs don't seem aware that their colleagues are advocating this radical message might give them pause.

Does this mean that the Kaiser members received bad quality of care through community providers? Yet Kaiser authorized services with sub-quality health care providers. It does not appear that historically Kaiser has been concerned about quality give these referral patterns. How can you trust this system? Anonymous

Just becuase one looks to improve quality and service does not mean that current or past quality was sub-quality. Kaiser has been concerned with the care and level of health services provided since the beginning and is only looking for ways to continue to improve. Kaiser will do something like this again in the future if it appears it will result in better care at that time. Honestly trusting healthcare systems is a tough thing to do though. Please understand that Kaiser is always member oriented first. Biased

Dr Weisz's energy is famous, if not infamous. It will be interesting to watch the course of his presence at KPMG. I agree there is a strong role for NPs and PA's in specialty care, where frequently referrals do not require the services of a subspecialist physician/surgeon. I do not, however, see that enhancing their roles in specuialty care is in oppostiion to the role that NP's/PA's also currently fill as primary care providers. The quality and service they provide to patients in primary care has been amply demonstrated to equal that of their phsyician colleagues. At risk of stating the obvious, to better address its primary challenge (which has always been access) while maintaining fiscal responsibility to its membership, Kaiser ought simply to recruit more NP's and PAs, both for specialty AND primary care settings.

I have been an employee, patient, and member of Kaiser in the Northwest. Some of my experiences were good; however, the ability to navigate through the system is horrible. Even as an employee, I got the run around. They want people to "Thrive". That sounds great, but they want you to "Thrive" with little support or help. They especially don't use that practice on their employees. I have a few family and friends that still work for Kaiser. It has never changed. They use you up and then spit you out. Kaiser is also not very wise when it comes to spending member's premium dollars on salaries and bonuses. The salaries paid to higher level management is obscene. Of course, you don't see a whole lot of that money being reinvested back into aging facilities. If you haven't been in some of those clinics and buildings, you should. Talk about taking you back in time! Kaiser could be great if it stuck to its core strengths, but Kaiser wants to be everything to everyone. Now when I see Kaiser. I just feel sad for them. It's like watching a species slowly falling into extiction.

Reading Dr. Weisz's plans to shrink their model of seeking Expert care outside of the Kaiser System is disappointing to one who has been a customer and patient of Kaiser for more than 4 decades. When considering a change of Healthcare and Insurance years ago, we chose to stay with the Kaiser system regardless of the costs to us personally, because of their forward thinking regarding contracting with specialty providers outside of Kaiser when needed. Our family has continued to grow, and have all stayed with Kaiser as our first choice in preventative care and their ocassional referral to expert provider care where that expertise is not present in their system. It simply made good medical, and financial sense. We sincerely hope that Dr. Weisz's choice of eliminating referrals to specialists outside of the Kaiser system changes. If this decission is based solely on costs, I suggest that they check with customer satisfaction, and individual case cost reduction prior to making a radical change. Their existing plan has served Kaiser and their Patients well during the past several decades of fine healthcare services in the Tri-county area.

It's pretty basic knowledge that even early stage breast cancer needs radiation after lumpectomy, with a few exceptions, like older ER+ women. It completely understandable that Dr. Weisz may not be an expert in this field. But the statement like this is misleading and sends the wrong message.

Having moved here from Kaiser Southern California in 2005, I also believe exercise is the fifth vital sign, but I am against transitioning NP/PA practice out of primary care and statements polarizing NP/PA practice. Some NP/PA folks kept their jobs during the transition in So. California Kaiser because their value was supported by their patients and by the physicians they worked with, and this is a context from which to begin to find solutions to better health care. Phenomenal care for every patient, every time, and each person feeling valued by Kaiser Permanente can be achieved by teams of highly trained and motivated people (physicians, NP/PAs, RNs, MAs down the list). Close working relationships based on mutual respect and open communication, collaborative dialogue and decision making, foster innovation, the ability to get to know every patient, and ultimately provide the best diagnosis and care, and cost and time savings. And what about job satisfaction? It leads to better patient care. Kaiser Northwest has the technology and the staff to be the best health care delivery system in America. The culture is open and collaborative. I hope the new direction of leadership takes this ball and runs.

I have had a PA as my primary care provider for many years. I have absolutely nothing negative to say about the level of care I have received. My PA is highly-skilled, knowledgeable, thorough and approachable. A few years ago I had an issue which led me to the Urgent Care clinic. From there I was seen by three separate MDs, each of whom failed to listen to my description of my symptoms. Instead, they each told me that there was nothing wrong. I went to my PA, explained what was going on, and was relieved when she found that I DID have something wrong. She correctly identified the problem and sent me to a specialist to have it treated. I followed my PA to a different clinic rather than switch to a primary care physician that I had no relationship with. If Dr. Weisz is really interested in reducing costs, I do not see how taking qualified and experienced PAs and NPs out of primary care will accomplish that goal. I want to keep my PA, thank you.

With regards to obtaining health care at an affordable cost, the general public wants their cake and they want to eat it too. You cannot expect health care costs to go down, or be affordable without changing how care is delivered and controlling costs. When my wife and I first moved to Southern California, we were completely foreign to the Kaiser Permanente delivery model, and my wife was a little put off. However, after our first few care experiences, she quickly changed her mind. After experiencing the ease of communicating with our doctors through email and phone, making appointments online, getting lab results the same day online, getting last minute appointments when warranted, we realized how inefficiently our previous care was being delivered. Soon many types of care are going to be delivered over the phone and via Skype because it will be a necessity in order to deliver quality care at a lower price. Physicians, patients, hospitals, health insurers, and the government will have no choice but to scrap the previous delivery model and innovate and change the way they do business. Jeff Weisz is just pushing forward that innovative change now so it will not be forced upon Kaiser Permanente and its patients by the government or economic forces.

I find it shocking that Dr. Weisz chose to announce his "plans" to reorganize utilization of Kaiser primary care NP's and PA's into "niche care" through a public interview with a journalist rather than holding a forum with these professionals to discuss his thoughts and position beforehand. It is dismissive, and unprofessional and his statements are ignorant and out of touch. Embarrassing that Kaiser Permanente has hired someone in this position who lacks the very basic knowledge of the education and qualifications of this large group of primary care providers who are so hard working, devoted to their patients, the system, and reaching quality goals equal to their MD colleagues.

Dr Wies, your proposition is curious. What is the evidence for your initiative to reduce the scope of work for physician extenders? How do NPs and PAs compare to physicians with-in their licensed scope of work for quality and patient satisfaction? I would expect/hoped Kaiser would not have employed them for years if there was any reason to believe they were not competent in both quality and patient interface. Is it cost for care? Is it less expensive to replace them? I am from an evidenced based understanding and this makes no sense to me, so I would like to know what I am missing.

While I have applauded Dr. Weisz's accomplishments in the realm of physician management (greater emphasis on professionalism, reduced tolerance for unacceptable behaviors) I do see his acceptance and promotion of the AMA's physician-centric agenda as antiquated and counter to significant momentum to embrace advanced practice providers in primary care and established specialty areas. Healthcare got to the point it is today under this MD-only philosophy ... and it will take a paradigm shift regarding providership to effect any real change. In So. Cal he was famous for creating significant downward pressure on advanced practice opportunities that we are still undoing today under new leadership. There are many good reasons he was NOT successful in his bid to increase the retirement age of physicians in the southern california med group primarily so he could seek a third term as regional medical director. To all advanced practitioners in oregon I say: Bond together and create an environment of ZERO tolerance for downward pressure on your practice. KP needs you ... and you will certainly survive his leadership tenure.

The Physicians went to medical school, and the NPs, PAs and CRNAs went to graduate schools. So on the one hand you have a group of individuals who were socialized as elitists that medicine is their business, that they are never wrong, should always be in charge and should always make more money than anyone else in the clinical healthcare system. And on the other hand you have a group of individuals who were socialized to listen to patients and be caring to them, to be thorough in assessment, and accountable for a plan, its implementation and evaluation. Yes---Dr. Weisz went to medical school. FG

Does high quality care at Kaiser include incompetent medical doctors who don't touch a patient ONCE during an ER visit who is dx of extremely elevated liver enzymes (10-fold)? Dr Weisz please answer this question. Concerned southern California member who happens to be an NP