Also read: Kaiser, medical center, careers, LGBT care, patients
Currently, 1 percent of Americans incur 35 percent of all healthcare costs. At the same time, preventable diseases such as diabetes and heart disease among traditionally underrepresented groups are increasing. The system is broken. How can we have quality, affordable care for all?
To find out, DiversityInc's CEO Luke Visconti sat down with George C. Halvorson, chairman and CEO of Kaiser Permanente (No. 7 on The 2009 DiversityInc Top 50 Companies for Diversity® list). Here are edited excerpts of their conversation.
Click here to read "The 9th Annual DiversityInc Top 50 Companies for Diversity®."
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Click here to read "Healthcare: Closing the Disparities Gap."
Luke Visconti: Your team is incredibly diverse. When did it dawn on you that diversity was a better way to go?
George C. Halvorson: One of the things was later on in my career. I actually went down to Jamaica and started an HMO about 25 years ago. It's still running. I was the founding CEO, not the owner; the owners still own it. Every single person that I worked with was Black. And so the boards of directors were Black, the doctors were Black, [as was] the customer base. Jamaica has some white people, but they weren't in my world for what I was doing down there. That was an incredibly liberating experience, because I flipped out of the stereotype of [seeing someone as] Black and a person I knew into somebody who was a person who happened to be Black. That was an interesting moment of truth
Even before that I was the only white part-time writer for [a Black] newspaper in Minnesota. I always had the predisposition toward enjoying more diverse culture in terms of friends. But the Jamaica experience took me one more step. I had a predisposition, but it was just to be the only white person in an environment for periods of time. One of the things I learned at that stage in the game was the fact that if you were the only something in the group, that can be really extinctive and intimidating.
I had one particular moment when I went to a reggae festival in the capital of Kingston on the beach. I was the only white person in the group. I had an absolute epiphany. My knees melted. I mean I actually lost it. A kid came over, took me by the arm and helped me get back into town. I started thinking: There's all kinds of things going on emotionally that had been off my radar screen. I had walked through the streets of Kingston in the middle of the night before with no problem, and then all of the sudden, I had the feeling of being the "other." You probably have never felt it, but it's an interesting feeling. It was my first time and it was like, "Holy cow!"
Then, later on, I did some health plans in Uganda and I had a similar experience at night in a village market. Again, I was the only one of me and had the same kind of panic feeling. I knew what it was then, but it still wiped me out.
Visconti: So when you put all of this together with healthcare, where do you come out? What's really behind healthcare disparities? Isn't it poverty, socioeconomic class and lack of access to resources.
Halvorson: There's that and there's also unconscious bias. One study [found] physicians treated African-American patients versus white patients who were having heart-attack symptoms totally different … Same setting, same socioeconomic status, everything identical [but] the difference being race. And the physicians were completely, totally convinced--they passed a lie-detector test--that they were doing nothing prejudicial.
There are many factors, and some are biological. There are differences in the likelihood of becoming diabetic, for example. Some of the issues are economic. African-American kids are half as likely to be treated for asthma, four times as likely to die of it. So you have those issues, and that's a straight care disparity, and then you've got the disease of unconscious bias. There's a whole array of issues that come into play, and if we're going to get good at this, we have to understand all of them.
Visconti: Many people in our country do not have access to healthcare because they don't have insurance. What's the solution?
Halvorson: Right now, about 10 percent to 12 percent of the premium charged to people who are insured is cost-shift premium, and it pays for the care of the uninsured. The uninsured people are disproportionately minority and are getting inadequate care as a result of not being insured. So, kids with asthma aren't getting preventive asthma care. People with diabetes are waiting until they're in the acute stage of the disease before they get treatment. Emergency rooms are being used as the treatment site. If we did a better job of identifying the issues and interacting much earlier in the process, we can bring down the cost of care, improve the quality of care and insure everybody. We're thinking of this as a combination of a sheer logistical issue; we need everyone covered.
In my new book ["Health Care Reform Now! A Prescription for Change"], there is a section that talks about the people who are uninsured [and how] they don't have any connections at all because they're in and out of [healthcare] databases, in and out of care sites, and there's no continuity of care for the population that desperately needs continuity of care through improved care. We'll never improve the healthcare system until we: A) cover everybody, and B) have everybody in [a central healthcare] database. Then, we can intervene in a systematic way.
One of the points I make in the book that people don't tend to make is people keep thinking these are separate streams of work--that coverage is separate from care improvement. They're inexplicably linked. And we have an interesting perspective here [at Kaiser] because we have the hospitals, and the doctors, and the pharmacies, and we're accountable for a population … We have to think much more holistically and broadly about the toolkit needed to take care of a population that is in some cases acutely ill, in other cases chronically ill, in some cases progressing toward one or the other. And how do we intervene appropriately, coordinate appropriately? And that is why we have done electronic medical records for all of our people, because we knew that we couldn't deliver the best care unless we had all of the information about all of our patients all of the time. We invested $4 billion in that.
Visconti: What do we need to do as a nation?
Halvorson: We need universal coverage. We need everybody covered. We can't have "us" and then "them" on coverage. Everybody in the country has to be in the insured population. Then, we have to provide care and deal with the issues of diabetes, heart disease and asthma, collectively. If we do that, then we can have much better care and reduce total cost of care. As a country, we need to go down that path, and then one of the things that I've been saddened, but not surprised, by was the fact that a number of people who shared my desire to cover everybody don't like to talk about the fact that the majority of the uninsured are minority. I've literally been told, "Don't mention that because the majority population will fall away and not support it."
So I've had to wrestle with that, with the ethics, and then talk to folks about it. We have to say that this is a civil-rights issue. We need to go to people who need to make the right decisions and say this is an issue where you should feel guilty for not doing, as opposed to not mentioning the issues because we might lose people.
Everybody needs to be in the risk pool, the healthy and the sick; otherwise, risk pools don't work. In my new book, I actually have a chapter on the villages in Uganda where we set up [healthcare] co-ops in villages. But we didn't activate the co-ops until 75 percent of the people joined because if you activate it at 25 percent, the premium made it way too high and the plan was unaffordable. We could never get to 100 percent enrollment because people didn't have the money. But 75 percent was good enough. When we got 75 percent of the people to enroll, then they kept [the healthcare co-op]. Because of that, the healthy people hadn't paid a premium, and that subsidized the sick people and the whole thing was affordable and it worked. It's risk-sharing that works. In those villages, if they would have activated when the first 10 people would have enrolled, the plan would have been dead in months.
Visconti: That's the whole point of your book--that we have to then manage the health of those people. Is that right?
Halvorson: Right. And then we have to take the folks who have conditions and make sure that we have more care for them. We have to make sure that their blood pressure stays down, their cholesterol levels stay down. And, if they're diabetic, make sure that we're checking the eyes and feet, because you can cut the amputations in half, the kidney failures in half by doing a much better job of managing their care. You can also cut the number of people who become diabetic in half by walking 30 minutes a day, four days a week. The opportunities are there ... to cut that and also improve care. [But] we need people with coverage, because people can't do that until they have coverage. If the coverage is badly designed so that it creates barriers to that initial care, then that's a major problem because then people don't fill their prescriptions and don't manage their [health]. So the benefit package should support care delivery and not impede it.
About George C. Halvorson
George C. Halvorson was named chairman and CEO of Kaiser Foundation Health Plan and Kaiser Foundation Hospitals in March 2002. He was formerly president and CEO of Minneapolis-based HealthPartners and had previously held several senior-management positions with Blue Cross and Blue Shield of Minnesota. In addition, Halvorson is the author of numerous books on healthcare systems, including the most recent "Health Care Reform Now! A Prescription for Change" as well as "Health Care Co-ops in Uganda, Strong Medicine" and "Epidemic of Care." He has served as an adviser to the governments of Uganda, Great Britain, Jamaica and Russia on issues of health policy and financing.
This article appeared in the May/June 2009 issue of DiversityInc magazine. Click here to read the digital version of this story.
