64 THE HEALTH PLAN-BUSINESS ASPECTS bers. When increasing membership required that the beds be returned to acute service, the hospital days per 1,000 members reverted to the pre-extended care level. This basic utilization data compiled over the years, as we have extended our coverages, is of inestimable value in planning future facilities. Knowing the population to be served, its characteristics, and its rate of growth, we can forecast how this population will utilize services. The ability to forecast is based upon even more precise data. For example: 1. Doctor office visits per 1,000 members, by specialty (Appendix Table 20). 4. Laboratory procedures per member or per 1,000 members per year, both 5. Prescriptions per member or per 1,000 members per year. FIGURE VI-3 Kaiser Foundation Health Plan, Southern California Region, Trend of Hospital Patient Days Per 1,000 Members, 1961-1970 APPLICATION OF UTILIZATION DATA The application of this data can best be illustrated by outlining the planning process for the new 200-bed medical center in West Los Angeles. It is projected that the membership to be served by this new center will approximate 100,000 when it opens in early 1974. In planning a new center, the general location is identified by areas where membership is known to be building and areas where a new facility would appear to provide relief to existing facilities. We can also predict to some degree the effect of opening a new facility on the existing medical centers, since computerized records are maintained on all hospital admissions by the zip code origin of the patient. Annually, the admissions from each UTILIZATION DATA AND THE PLANNING PROCESS 65 zip code area are analyzed and total health plan population residing in each area is allocated to the medical centers according to the percentage of admissions that a given center received. This method of allocation is presently being refined by a continuing 5 percent sample of doctor office visits by zip code origin to provide further data to substantiate or dispute the validity of allocating population on the basis of hospital admissions only. BEDS PER THOUSAND MEMBERS Historically, for planning purposes, we have spoken loosely in terms of the need for two beds per 1,000 members. The rapid membership growth in Southern California has never permitted us to attain this planning objective (Figure VI-4). This is in spite of having been closed to new groups, with one exception, since 1965. Experience during this period indicates that 1.8 beds per 1,000 members is realistic and present planning and financing is geared to this ratio. This should be viewed as a regional guideline not necessarily applicable to each location. It should also be pointed out that the graph in Figure VI-4 represents the beds available per 1,000 members; not the occupancy rate. It is our firm conviction that if one has more beds than experience indicates is necessary to serve a given population, the utilization rate increases. FIGURE VI-4 Kaiser Foundation Health Plan, Southern California Region, Trend of Hospital Beds per 1,000 Members, 1961-1970 The breakdown of beds by major categories at the 1.8 beds per 1,000 member level is shown in Table VI−1. Also portrayed are the actual beds in service in Southern California as of January 1, 1971. Southern California is presently operating at approximately .2 beds per 1,000 members below the desired objective of 1.8 beds per 1,000 members. This illustrates the difficulty in maintaining perfect balance among membership, physicians, and beds. The lower than desired bed ratio resulted in an overall average occupancy rate of 91 percent in our acute beds during 1970. It requires us to arrange periodically for outside beds until such time as we bring new beds into service. Our present $70,000,000 building program in Southern California is designed to restore this balance. PHYSICIANS PER THOUSAND MEMBERS One ratio frequently applied to Kaiser-Permanente is one physician per 1,000 members. This ratio is employed primarily for facility planning purposes. As shown in Figure VI-5, we have never actually attained this ratio. It should be recognized that the narrow range over the past decade is not something that “just happened.” It was planned to meet the needs of the membership and can be related directly to the stability in the doctor office visits per 1,000 members and the hospital utilization data. In planning physician staffing for the new medical center, the Southern California Region uses one physician per 1,000 members as a guideline. Ratios have also been developed for each specialty recognizing that local areas within a large region have their own characteristics that have to be recognized in the planning process (Table VI-2). Certain guidelines such as one obstetrician per 10,000 members, and UTILIZATION DATA AND THE PLANNING PROCESS 67 FIGURE VI-5 Kaiser Foundation Health Plan, Southern California Region, Trend one general surgeon per 12,500 members are starting points for modification in meeting local requirements. Some mention should be made of the relationship between internal medicine, general medicine, and pediatrics. A higher ratio of generalists associated with the medical center, whether practicing within the center or in an outlying clinic, will usually affect the overall ratio of internists and pediatricians. In Southern California, when combining internists and generalists, we use as a guideline approximately one physician for each 2,250 members. If one adds pediatricians to the equation, the ratio becomes one physician to 1,650 members. Thus, planning for a membership of 100,000, we think in terms of 60 physicians to cover internal medicine and pediatrics, recognizing some portion of the care in both specialties will be rendered by generalists (Table VI−2). Two other specialties warrant comment. We plan on one ophthalmologist per 50,000 members. We have integrated optometrists into our medical group organization and utilize 2.5 optometrists per ophthalmologist. In Southern California, the medical group utilizes nurse-anesthetists for the bulk of the anesthesia. Approximately six nurse-anesthetists will support the one anesthesiologist shown as required for 100,000. For planning purposes we have also developed ratios for the number of examining rooms for each specialty and the special support space required in the medical office building, also by specialty. The West Los Angeles Medical Center is an expandable facility designed to grow to 400 beds when required. Consequently the physician staffing needs, by specialty, to serve a population of 200,000 have been developed as part of planning the total project. 68 OTHER EMPLOYEES THE HEALTH PLAN-BUSINESS ASPECTS Responsibility for quality of professional service is a responsibility of each physician and the medical group as a whole. This responsibility encompasses both inpatient and outpatient activities. Within our organizational structure, the administrative responsibility for radiology, laboratory, and physical medicine is within the medical group. Therefore, when one examines the number of additional employees per 100,000 members, or per 1,000 members, on the medical payroll, one must bear in mind that personnel working in these areas are included in the manning tables. The figure of 2.91 allied medical group employees per 1,000 members is a regional figure (Table VI-3). It will vary from center to center, depending on services provided and specialties represented. The ratio is readily convertible to number of allied employees per physician by type which is a very useful management tool in budgeting and in evaluating a location's performance. During 1970 in Southern California, the physician/member ratio was one physician per 1,056 members producing an average of 3.18 additional employees per physician.2 TABLE VI-3 Southern California Permanente Medical The total number of allied or nonphysician employees per 1,000 members in Southern California is approximately seven (Figure VI−6). This includes, in addition to employees of the medical group, hospital employees, and employees of the health plan and Southern Permanente Services. The breakdown per 1,000 members is reflected in Table VI-4. Of the 7 employees per 1,000 members-2.91 are in the medical group, 3.24 are in the hospitals, and .85 are employed in the health plan and Southern Permanente Services. At present in Southern California, the hospitals operate at a ratio of 1.8 employees per bed. 2. Because only a portion of our members have psychiatric coverage the need for psychiatrists and associated personnel is not universal throughout our program. For this reason, psychiatrists are not shown in the basic physician staffing requirements but are included in the "allied" category. |