CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A STUDY INVESTIGATING
II
CROSS-OVER UTILIZATION OF
TWO
KAISER-PE~~ENTE
MEDICAL CENTERS
BY THE MEHBERSHIP
A Masters project submitted in partial
satisfaction of the requirements for the
degree of Master of Science in
Health Science, Health Administration
by
Nadya Verabian
-----
June, 1980
The thesis of Nadya Verabian is approved:
Waleed Alkhateeb, Dr.P.H.
Catherine
McCaslin~
Ph.D.
California State University, Northridge
DEDICATION
This masters project is dedicated to the memory of
the late John
c.
Dumas, Director of Regional Planning,
Kaiser Permanente Medical Care Program (1975-1978), whose
unique and creative approach to ,health planning provided
inspiration to all of us who worked with him.
The researcher is indebted to Mr. Russell B.
Williams, Vice President and Associate Regional Manager of
Kaiser Permanente Medical Care Program, for sponsoring the
study, and to Richard Brannin, his staff, and Caroline
Meltzner whose advice was invaluable.
I thank the members of my thesis committee, Donald
M. Hufhines, Dr.P.H. for setting up strict standards of
quality and leadership, Waleed Alkhateeb, Dr.P.H. for his
consistent support and encouragement, Catherine McCaslin,
Ph.D. for expert advice and direction.
I could have never completed this work without the
love and understanding of my husband Aram, and my sons
Greg and Mark.
TABLE OF CONTENTS
Page
i
Dedication
List of Tables
ii
Abstract
Chapter 1
iii
INTRODUCTION
Introduction
1
Statement of Problem .
.
3
Organization of Paper
Chapter 2
7
BACKGROUND
Background .
.
.
.
.
8
Review of Literature . .
8
Setting of Project . . .
11
Chapter 3
METHODOLOGY
Statement of Project
13
Sources of Data and Their Measurement
15
Analysis of Data .
19
.
Limitations
Chapter 4
RESULTS .
Chapter 5
CONCLUSION
20
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
22
53
Recommendations
54
Summary
55
I
TABLE OF CONTENTS
BIBLIOGRAPHY .
.
.
.
.
.
.
.
.
APPENDIXES
.
.
.
.
.
.
.
.
Page
57
58
A - Sample Survey Letters
59
B - Sample Questionnaire
61
C - Zip Code Map
65
'
TABLES
Table
Page
1.
Length of Membership .
.
.
23
2.
Location of Most Recent Hospitalization.
.
25
3.
Table Showing Frequencies of Reasons
for Choosing Sunset . . . . . . . .
4.
5.
6.
7.
.
. .
.
.
. .
Table Shows Frequencies of Number
of Years With Regular M.D. at
Sunset . . . . . . . . . . . . .
.
26
. . .
~
28
Age Breakdown of Long Term Members
(9+ Years) Who have an Established
Family M.D. at Sunset . . . . . . .
31
Having Personal M.D. at Sunset as
Related to Length of l·1embership.
32
Facility Most Often Utilized After
Hospitalization. . . . . . . . .
34
8.
Reasons for Choosing West Los Angeles.
9.
Reason for Hospitalization by Service
Type
. . . . . .
. . . .
37
For Hospitalization by Service Type
Receded. . . . . . . . . . .
38
The Pediatric Facility Utilized by
Ex-Maternity Patients From Sunset.
40
10.
11.
12.
Out-Patient Facility Utilized by
Ex-Maternity Patients From Sunset.
.
.
.
35
41
13.
Additional Comments-Coded . .
43
14
Percentage of Members From Each
Zip Code Who Thought Traveling
to Sunset Took the Least Amount
of Time . . . •· . . . • . . . . .
50
ii
ABSTRACT
A STUDY INVESTIGATING
CROSS-OVER UTILIZATION OF
TWO KAISER PERMANENTE MEDICAL CENTERS
BY THE MEMBERSHIP
BY
Nadya Verabian
Master of Science in Health Administration
An
analysis of hospital utilization data had
revealed that a large percentage of Kaiser-Permanente
members residing in the Kaiser West Los Angeles Medical
Center service area had been hospitalized at the Kaiser
Los Angeles (Sunset) Medical Center in 1978.
If
geographic proximity were the primary factor in a
member's choice of a particular facility, it would
follow that members residing in close proximity to
Kaiser West Los Angeles, would be obtaining care at that
medical center.
iii
A survey was conducted to assess factors
influencing the utilization behavior of KaiserPermanente members with regard to facility selection.
To
determine the relative importance of these factors was
significant due to regulatory requirements with regard to
bed utilization, site selection for new medical centers,
expansion and membership allocation within the KaiserPermanente Medical Care Program.
The survey sample was drawn from the population
showing the "cross-over utilization" trends.
The results indicated that the majority of the
mE:.!Llber sample who were hospitalized at Sunset had been
with the Program a long time.
67% had been members for
over 9 years. Additionally, 60.7% had an established
physician/patient relationship at Sunset and, identified
this relationship as the most important factor in
utilizing the Sunset facility.
Based on the results of the study, it was
recommended that when selecting sites for new facilities
and planning member allocations, the Program should take
into account that in addition to geographic proximity to
a medical facility, the presence of a prior satisfactory
physician/patient relationship will influence
utilization patterns.
iv
Chapter 1
INTRODUCTION
I.
INTRODUCTION
The Kaiser-Permanente Medical Care Program is a
direct service group practice prepayment program which
became qualified as a Health Maintenance Organization in
October, 1977.
It is the largest private provider of
health services in the United States, having over 3
million members in six states:
California, Colorado,
Hawaii, Ohio, Oregon, and Washington.
The Kaiser-Permanente Medical Care Program has
three principal operating units:
A.
Kaiser Foundation Health Plan, Inc.
This is
a non-profit organization that enrolls members
for the health plan and arranges for those
health care services.
voluntary basis.
Membership is on a
To arrange for health care
services for the membership, the Health Plan
contracts with six Permanente Medical Groups
and Kaiser Foundation Hospitals.
1
2
B.
The Permanente Medical Groups.
These groups
are organized as partnerships or as
professional corporations.
They function on a
group practice basis and provide comprehensive
professional services to health plan members.
C.
Kaiser Foundation Hospitals.
This is a non-
profit organization which assumes
responsibility for providing hospital services
to members enrolled in the health plan and to
people in other categories of the communities
in 1.vhich they operate.
Kaiser-Permanente has been directly responsible for
organizing and delivering comprehensive, quality health
care to a defined population (3,284,478 members) on a prepaid basis. To do this, Kaiser-Permanente employs 3,000
full-time medical doctors and 25,000 non-physician
personnel.
It owns 26 community hospitals with 5,785 beds.
There are 70 medical office facilities. 1
The Southern California Region serves 1,360,462
Health Plan members, covering a service area of 5,700
square miles.
The Region's Medical Group employs· 1,400
full-time physicians.
The Region's northern boundary is
lAll data based on Kaiser Foundation Health Plan
statistics of March 1979.
3
in Lancaster, southern boundary in San Diego.
The eastern
facility is in San Bernardino, and the western in West Los
Angeles.
In order to serve the 1.3 million member population
who are geographically dispersed throughout the region,
the program operates 21 outlying medical office facilities
as a convenience to members for primary outpatient care.
These medical offices serve as satellites to one of the
eight regional medical centers.
II.
STATEMENT OF PROBLEMS
A.
Problem
In 1974, the Kaiser-Permanente Medical Care
Program opened the West Los Angeles Medical Center based
on growing patient demand for facilities and services by
the Health Plan members residing in the West Los Angeles
area and based on the projection of a drawing region of
140,000 members living specifically in the areas of
Malibu, Santa Monica, Beverly Hills, West Los Angeles,
Culver City, Venice, and Inglewood.
Since the Medical
Center was geographically located near the boundaries of
the above areas, it was assumed that it would draw from
and serve the needs of the Kaiser-Permanente membership
residing infuat area.
If geographic proximity were the
primary factor in a member's choosing a particular
4
facility, it would follow that the membership residing in
the above areas, who were currently using other KaiserPermanente Medical Centers, would alter their pattern of
utilization in terms of facility location and
predominantly use the West Los Angeles Medical Center.
Thus, members who were using the Los Angeles Medical
Center at Sunset Boulevard and Edgemont, and who resided
in the West Los Angeles area, would nov; go to the West Los
Angeles Medical Center for Medical care.
A preliminary analysis of hospital utilization data
comparing the volumes for Los Angeles (Sunset)2 Medical
Center and the West Los Angeles Medical Center shows that
a significant percentage of Kaiser-Permanente membership
residing in the areas of
~1alibu,
Santa Monica, Beverly
Hills, West Los Angeles, Culver City, Venice and
Inglewood have continued using the Sunset Medical Center.
This medical center has severe site restrictions, and
continued growth for primary and secondary health care
services appears limited.
The West Los Angeles Medical
Center, on the other hand, has the capability of
increasing capacity as part of its long-range master plan
for physical development.
This master plan was formulated
2The name Sunset will be used throughout this
paper to represent the Los Angeles Medical Center.
5
at the inception of the West Los Angeles Medical Center,
If the current flow of patients from the West Los Angeles
area to the Sunset facility can be redirected to the West
Los Angeles facility, both medical centers would be able
.to improve services and access to the Kaiser-Permanente
members.
B.
Objectives
To determine the relative importance of factors
influencing utilization of facilities by the KaiserPermanente membership.
C.
Significance of the Problem
Determining the relative importance of factors
influencing facility selection by the membership is highly
significant because of various factors:
1.
Regulatory requirements with regard to bed
utilization and occupancy rates.
At the present time, expansion of hospital
facilities and addition of beds is subject to
government regulations based on occupancy
rates.
2.
The factors to be considered in selecting or
expanding a new facility or medical center
site by the Kaiser-Permanente Medical Care
6
Program.
In selecting a new site, membership drawing
area, traffic and utilization patterns, as
well as demographic characteristics of the
membership population should be taken into
account.
3.
Future marketing implications for the KaiserPermanente Medical Care Program.
During a period of open enrollment,
utilization behavior of membership can provide
data for effective marketing.
4.
The feasibility and implications of assigning
membership to designated facilities within the
Kaiser-Permanente system.
At the present time, people joining the Kaiser
Foundation Health Plan in the Southern
California Region can obtain medical care at
any Kaiser facility throughout the region.
D.
Description of Study Type:
This is a descriptive study to determine the
relative importance of factors influencing utilization of
facilities by the Kaiser-Permanente membership.
7
III.
ORGANIZATION OF PAPER
This paper has been divided into five chapters.
Chapter 1.
This chapter provides an introduction
and outlines the significance of the problem in addition
to a definition of study type.
Chapter 2.
This chapter outlines a brief
historical perspective and further discusses the setting
of the project.
Chapter 3.
A definition of the project methodology
in terms of project objectives and sources of data and
methods of measurement is outlined.
A discussion of data
analysis and limitations of the study follows methodology.
Chapter 4.
Findings and results are discussed
with relation to study objectives and data is displayed on
charts.
Chapter 5.
from the study and
chapter,
A summary of the conclusions drawn
reco~~endations
are included in this
Chapter
2
BACKGROUND
I.
REVIEW OF LITERATURE
A.
A literature search was initiated to
investigate prior studies done with relation to the
project topic.
Even though various research studies can
be pointed outwith relation to "patient origin studies,"
"facility site selection for hospitals," "doctor/patient
relationships" and "factors affecting hospital choice,"
no material is available that is specific to Health
Maintenance Organizations.
Health Maintenance Organizations are a relatively
recent alternative to health care delivery.
Additionally,
very few Health Maintenance Organizations operate their
own in-patient facilities.
Thus studies directly relating
to the scope of this study were not available to the
researcher as a resource.
8
9
A study by Bashur, Shannon and Metznerl
investigating ecological differentials in the use of
medical services, concludes that the choice of hospital is
not necessarily on accessibility but that other phenomena
such as attributes of facilities and the values of users
play a part as they operate in "social space" as well as
''physical space".
A study by Abernathy, et a1, 2 showed that proximity
to a primary care facility influenced a family's choice of
that facility.
Choice declined'steadily as the center's
distance from the family increased.
A study by Weiss, J.D., et al,3 analyzed the effect
of distance between patient and provider on the utilization
of physician services in a metropolitan area.
Sample was
drawn from Kaiser Foundation Health Plan membership.
The
authors concluded that "when a diverse population shares
lRashid L. Bashur, Gary w. Shannon, and Charles A.
Hetzner, "Some Ecological Differentials in the Use of
Medical Services," Health Services Research. Vol. 6,
pp. 61-75.
2w. J. Abernathy and E.L. Schrems, "Distance and
Health Service: issues of utilization and facility choice
for demographic strata" Research Paper No. 19, Stanford
University, Graduate School of Business, 1971.
3J.E. Weiss, et al.
"Determinants of Medical Care
Utilization: the impact of spatial factors," Inquiry 8,
pp. 50-58, (December}, 1971.
10
a common source of medical care, travel distance becomes
a relatively important variable in the overall utilization
patterns of the population.
When visits to pediatricians and internists were
analyzed separate than specialists, 70% of all visits were
made to the nearest clinic.
A study by Robert L. Kane 4 exploring expectations
of a rural population with regard to location and type of
medical services for their region, revealed that emphasis
was on "care" rather than
"cure~'.
Comments of respondents
regarding a health care facility that had been closed in
their community were grouped.
The 188 comments offered
were divided as follows:
Good Treatment
70
Friendly Staff
51
Convenience
33
Good Equipment/Facilities
13
Favorable Admission Policies
Other
8
13
4Robert L. Kane, "Determination of Health Care
Priorities and Expectations Among Rural Consumers,"
Health Services Research, Summer 1969.
11
II.
SETTING OF THE PROJECT
This project was conducted within a six month
period during which the researcher was completing. an
administrative-residency program at the Regional Planning
Department of Kaiser Foundation Hospitals.
The data for the study was obtained through the
cooperation of Kaiser Foundation Health Plan, Information
Services Department, and the Department of Medical
Economics.
The Department of Regional Planning and
Medical Economics have been reorganized into one entity
titled Program Planning and Planning and Support Services
since January 1979.
The specific setting of the study involved Kaiser
Foundation Medical Centers at Sunset and West Los
~~geles.
Kaiser Foundation Hospital, West Los Angeles,
incorporates outpatient clinics adjacent to an inpatient
facility with 200 licensed beds.
The bed categories are
as follows:
Medical/Surgical
117
Intensive Care
46
Prenatal
22
Pediatric
15
12
Kaiser Foundation Hospital, Sunset, has 586
licensed beds situated adjacent to or in close proximity
with outpatient clinics.
It is the first in-patient
facility built for Kaiser members in the greater Los
Angeles area offering primary and secondary services in
addition to tertiary care services for most of the Southern
California Kaiser membership.
The following are the bed
categories for Kaiser Foundation Sunset Hospital:
Medical/Surgical
397
Intensive Care
36
Cardiac Care
34
Newborn Intensive Care
10
Pediatric
53
Prenatal
54
Chapter 3
METHODOLOGY
I.
STATID·ffiNT OF PROJECT
A.
Objectives:
1.
To identify whether'there is a relationship
between the following selected factors and the utilization
of a specific medical facility by a Kaiser-Permanente
member:
Factors - doctor/patient relationship, familiarity,
attitude of personnel, travel time to
facility, characteristics of facility,
quality of care, availability of specific
services, wait time.
2.
To assess the relative importance of these
3.
To compare differences in factors determining
factors.
facility selection between the (senior) Kaiser-Permanente
members who have been members for 9 years or more and those
who became members after 1974.
Center was established).
13
(After the West Los Angeles
14
B.
Definitions:
Primary Care:S
Basic or general health care which
emphasizes the point when the patient first seeks
assistance from the medical care system for the care of
the simpler and more common illnesses.
Secondary Care:
Services provided by medical
specialists who generally do not have first contact with
patients (e.g. cardiologists, urologists, dermatologists).
Tertiary Care:
Services provided by highly
specialized providers (e.g. neurologists, neurosurgeons,
thoracic surgeons, intensive care units).
Service Area:
An area with boundaries surrounding
all zip codes within a 30 mile radius from a KaiserPermanente Medical Center.
Cross-Over Utilization:
A pattern of utilization
where members statistically allocated to a medical facility
because of residence in the service area, will utilize
health care services at a medical facility located out of
the boundaries of their own service area.
SA Discursive Dictionary of Health Care, Staff,
Subcommittee on Health and the Environment, U.S.
Government Printing Office, Washington, 1976.
15
ill10:
Health Maintenance Organization.
organized system of health care
It is an
which assures the delivery
of comprehensive, continuous, coordinated health care
services to a voluntarily enrolled population on a prepaid
basis.
II.
SOURCES OF DATA AND THEIR
A.
~1EASUREMENT
As pointed out in Chapter 2 of this paper, studies
done on utilization of health care services point out many
factors that influence
utilizat~on.
To determine the relative importance of factors
influencing utilization of facilities by Kaiser-Permanente
membership, a random sample of Kaiser-Permanente members
(aged over 18) who resided in the service areas of the
West Los Angeles Medical Center were studied.
This
service area had been designated as encompassing 32 Zip
Code areas surrounding the Center.
can be found in the appendix.
A list of the Zip Codes
(See Zip Code Map in
appendix.)
B.
The Research Tool
A 14 point questionnaire (see appendix, Page61 )
was developed which tested the opinions and behavior of
Kaiser-Permanente members with regard to medical facility
selection.
16
C. This questionnaire and an introductory letter was
sent to a random sample of Kaiser-Permanente members (aged
over 18) who resided in the above service area and who were
hospitalized at Sunset Medical Center during 1977.
(The
West Los Angeles Medical Center was operational in
September 1974).
D. Through hospital utilization data obtained from
Kaiser Foundation Health Plan Information Services
Department, size of the population was determined to be
4,500.
This population represented Kaiser members who
resided in the 32 Zip Codes and who were hospitalized at
the Sunset Medical Center during 1977.
A 22% sample was drawn from the population by a
computer program designed for randomization.
was {N=l007).
Sample size
This sample was further reduced due to the
following factors:
1.
14 members with medical record numbers ending
in digits 44 did not receive a questionnaire
in order to avoid over-sampling of membership.
At the time of this survey, two other surveys
were being mailed out to Kaiser members with
medical record numbers ending in 44.
2.
1 address label was missing.
3.
2 members who were identified as Kaiser
physicians were not mailed questionnaires.
17
4.
23 members from the sample were randomly
selected for pretest and were later
excluded from the sample.
N
Less
Total
questionnaires mailed
=
1007
-40
967
Questionnaires were mailed with a cover
letter from the Executive Offices of
Kaiser Foundation Hospitals (see
I
appendix,
pg~).
18
Questionnaire Return Analysis
Pretest
Mailed
n
% of
total
sample
23
2
Returned completed
57
Not deliverable
4
No reply
Survey
39
Mailed
967
Not usable
1.3
Not deliverable
8
Returned too late to
be included in analysis
5
32
Not returned
Total usable replies
53.7
519
Actual return rate - 519 + 13 + 52
=
584
60.4%
Three weeks after the first mailing, a second
questionnaire was sent to all those who had not returned
the first questionnaire.
Incorrect addresses were also
eliminated from the sample during the second mailing.
19
III.
ANALYSIS
In order to determine the relative importance of
factors influencing utilization of facilities by the
members, the following procedures were conducted with the
data:
A.
Frequencies of responses were obtained on all
informational questions. The results, in
percentages, were used to assist in comparing
the response data.
B.
The data was examined to see if there is a
difference in responses between the (senior)
members and the newer members.
C.
The correlation between the variable of length
of membership and presence of a physician/
patient relationship was analyzed.
D.
Various cross-tabulations were performed with
the results.
It was predicted that the established doctor/ .
patient relationship between a doctor and member would be
the most frequently stated reason for choosing a facility
by the members who had been members for 9 years or more.
In the case of members who joined the Kaiser Foundation
Health Plan after September 1974, who reside in the service
20
area designated by this study and were using the Sunset
facility, it was predicted that the above would not hold
true, and the most frequently stated reasons would be
evenly distributed among the possible choices.
IV.
LIMITATIONS OF THE STUDY
A.
Ideally, all Kaiser-Permanente members who
resided in the area designated by this study and used
any medical services at the Sunset Medical Center should
have been surveyed, not only those who were hospitalized
at Sunset.
This data would have been extremely difficult
and costly to obtain.
Therefore, for the purposes of
this study it was assumed that hospitalization is
initiated at the Medical Center which a member uses for
outpatient medical services, although there are other
means to direct patient referrals within the system.
B.
Another limitation of this study was that a
control group wasn't used since the project problem was
more significant in terms of the West Los Angeles and
Sunset Medical Centers than for other Kaiser-Permanente
Medical Centers which show the same cross-utilization
trends.
For example, the same trend was seen between the
Harbor City Medical Center and West Los Angeles Medical
Center, Panorama City Medical Center, and the Sunset
Medical Center.
Only West Los Angeles and Sunset Medical
Centers were singled out for the purposes of this study.
21
Using cross-over utilization data for other Medical
Centers would have provided a control group.
This study does not presume to yield definitive
answers, but merely becomes a pilot study which analyzes
a problem that has significant implications for the KaiserPermanente Medical Care System and also provides a basis
and direction for further study of the issue.
Chapter 4
RESULTS
I.
GENERAL SU!1MARY OF FINDINGS
A summary of frequency of responses reveals the
following:
Question 1.
Length of Membership
As indicated by Table I, 67% of the sample had
been members for over 9 years.
A further content analysis
of individual responses indicated that a majority of the
67% had been members for over 15-20 years.
From comments
that these members included in the questionnaires, it was
apparent that they joined the plan soon after its
establishment,
(when Sunset was the only Center available)
they felt satisfied with and faithful to the Plan and
considered the Sunset Medical Center as "the Kaiser".
Question 2.
Have you ever been hospitalized in a
Kaiser Foundation Hospital?
Results:
99%; No - 2 - 1%.
The responses obtained were: Yes - 517 The two cases are attributed to members
who had gone through admitting procedures and subsequently
22
TABLE I
Length of Membership
LENGTH OF MEMBERSHIP
% FREQUENCY
n
1-4 years
15.3
79
5-9 years
17.7
91
9+
67.0
345
years
100.0%
516*
*In this and all subsequent tables, n's differ due to
variation in missing values.
IV
w
24
been released the same day after observation in the holding
area.
Question 3.
At which Kaiser Foundation Hospital
was your most recent hospitalization?
Results:
The purpose of the question was to obtain
a double check on the sample.
The time lapse from 1977 to
March 1979 when the survey was mailed, accounts for
responses on more recent hospitalizations.
As indicated
by Table II, 3% of the members reported having been
'
hospitalized at other Medical Centers
since the 1977
hospitalization.
Question 4.
Why did you choose Sunset?
(Check as
many as apply.)
Results:
Table III shows that there was a
significant difference between the number who chose "My
Regular M.D. Practices at Sunset" and all the other
categories.
While the frequency of a positive response to
the other categories varied from only 10.8% to 23.9%, a big
majority, 60.7% checked "My Regular M.D. Practices at
Sunset".
Table IV shows frequencies of response for number
of years (1-30 years with personal M.D.).
Additionally, as
indicated by Table V, of these members who had an M.D. at
Sunset and who had been members for 9 years or more, 46.4%
were over 65 and 34.8% between the ages 45-64.
Table VI
portrays the results that having a personal physician at
TABLE II
Location of 1Jlost Recent Hospitalization
MEDICAL CENTER
% FREQUENCY
n
96.3
499
West LA
3.1
16
Other
0.6
3
Sunset
100.0%
518
IV
lJ1
'
TABLE III
Table Showing Frequencies of Reasons for Choosing Sunset
NOT CHECKED
CHECKED
%
40.
'
n
--%
n
I was referred by an M.D. from another
Kaiser Clinic.
10.8
56
89.2
463
41.
.My regular M.D. practices at Sunset.
60.7
315
39.3
204
42.
I have been with him/her for __years.
43.
Shorter waiting time to receive
service at Sunset.
44.
13.1
68
86.9
451
20.6
107
79.4
412
18.3
95
81.7
424
Traveling to Sunset takes the least
amount of time.
45.
(REFER TO SEPARATE SHEET)
I like Sunset because of its layout
and surroundings.
N
0'\
~
'~
Page 2 of Table III
TABLE III
Q. 4
(continued)
Why did you choose Sunset?
(Check as many as apply)
-~
CHECKED
46.
%
n
%
n
23.9
124
76.1
395
23.7
123
76.3
396
14.8
77
85.2
442
Better access at that time.
15.2
5
Close to work place.
30.3
10
Am familiar with Sunset.
33.3
11
Like a particular specialist.
21.2
7
I like the attitude of the personnel
at Sunset.
47.
I think the quality of care is better
at Sunset.
48.
The facility I regularly use does
not provide this service.
49.
NOT CHECKED
Other:
N
-....]
TABLE IV
Table Shows Frequencies of Number of Years With Regular M.D. at Sunset
NUMBER OF YEARS WITH M.D.
% FREQUENCY
- n
1
3.5
10
2
5.9
17
3
5.9
17
4
8.0
23
5
12.5
36
6
4.5
13
7
4.5
13
8
5.9
17
9
4.2
12
10
11.1
32
11
1.4
4
12
4.5
13
N
(X)
Page 2 of Table IV
TABLE IV
(continued)
Table Shows Frequencies of Number of Years With Regular M.D. at Sunset
NUMBER OF YEARS WITH M.D.
% FREQUENCY
- -n
13
1.4
4
14
1.7
5
15
6.9
20
16
1.0
3
17
1.4
4
18
2.1
6
19
0.7
2
20
5.9
17
21
0.3
1
22
0.7
2
23
0.3
1
24
1.0
3
N
\..0
Page 3 of Table IV
TABLE IV
{continued)
Table Shows Frequencies of Number of Years With Regular M.D. at Sunset
NUMBER OF YEARS WITH M.D.
% FREQUENCY
n
25
3.5
10
26
0.3
1
28
0.3
1
30
0.7
2
Total
289
w
0
TABLE V
Age Breakdown of Long Term Members (9+ Years}
Who Have an Established Family .t>LD. at Sunset
AGE CATEGORY
% FREQUENCY
n
18 -
24
0.4
1
25
44
L8.4
46
45 - 64
34.8
87
65 +
46.4
116
100.0
250
Total
w
1-'
TABLE VI
Having Personal M.D. at Sunset as Related to Length of Membership
Length of Membership (Years)
M.D. at
SUNSET
YEARS
1-4
YEARS
5-9
YES
26
38
250
' 1
0
315
NO
53
53
95
2
1
204
COLUMN
TOTAL
79
91
345
3
1
519
-----
YEARS
9+
NOT
~!EMBER
NOW
SKIPPED
ROW
TOTAL
I
I
--~-------~-
------------------------ -----
-----------
w
N
33
physician at Sunset is also positively related to Length
of Membership.
Refer to Table VI.
The responses to the category "Other" have been
tabulated separately.
Percentages on Table III will not add up to 100%
since respondents could check as many categories as
applicable instead of picking out only one.
Question SA.
After your most recent
hospitalization, which Medical
Center have you been going to
most often?
(Please check only
one.)
Results:
Since the utilization of outpatient
clinics is one of the main concerns of the Program and
shortage of space for growth one of the most acute
problems for the Sunset Hedical Center, the pattern of
outpatient clinic utilization was analyzed.
As
summarized in Table VII, the trend points to a higher
outpatient clinic utilization of Sunset then West Los
Angeles by the same population.
Question SB.
Results:
I Use West Los Angeles Because:
Table VIII shows that most of the
members who chose West Los Angeles as the primary
location for outpatient services, did so because of
geographic proximity.
TABLE VII
Facility Most Often Utilized After Hospitalization
FACILITY
% FREQUENCY
- n-
Sunset
66 .. 1
332
West Los Angeles
24.9
125
Other-No Facility Given
0.4
2
Other-Facility Given
1.2
6
West Los Angeles and Sunset
7.2
36
Sunset and Other Facility
0.2
1
100.0
512*
*t-1issing values {no response) not included into percentages.
w
ll:>o
TABLE VIII
Reasons For Choosing West Los Angeles
REASON GIVEN
% FREQUENCY
n
Easier To Get To
56.8
88
Family M.D. There
11.6
18
31.6
100.0
49
Both 1 and 2
Total
w
Ul
36
Question 6.
What was the reason for your
hospitalization at Sunset?
Results:
The large total for obstetrics was
expected since maternity care was not available at West
Los Angeles prior to June 1977 and maternity patients
had the option to be hospitalized at Sunset or private
non-Kaiser hospitals.
This can be seen on Table IX. The
results were recoded and depicted on Table X to
differentiate and display those services that were only
available at Sunset from those'that were offered at
Sunset as well as West Los Angeles.
Even though 23.9% of the hospitalizations were
for Obstetrics, 55.9% of all hospitalizations at Sunset
were for services that were available at both Sunset and
West Los Angeles.
Besides Obstetrics, Cardiac Surgery
and Neurosurgery were the only services where the members
did not have a choice of Medical Center, since those were
only offered at Sunset.
Further analysis of data showed that of those
respondents who checked "Service not offered at regular
facility" 62.3% checked Obstetrics and 13.0% checked GYN
as the service of hospitalization.
Question 7B.
Which facility do you go to for
Pediatric services?
TABLE IX
Reason For Hospitalization By Service Type
SERVICE TYPE
% FREQUENCY
n
Obstetrics
23.9
120
Gynecology
14.3
72
Internal Medicine
15.9
80
General Surgery
9.6
48
Neurosurgery
2.2
11
Orthopedics
3. 2-
16
Ear-Nose-Throat
1.8
9
Urology-Surgery
11.4
57
Ophthalmology
1.6
8
Cardiac Surgery
2.4
12
Other-No Reason
0.2
1
Other-Reason
3.2
16
10.4
52
100.0
502
Multiple Reasons
Total
w
-.....)
TABLE X
Reason For Hospitalization By Service Type
Recoded
-SERVICE TYPE
-
% FREQUENCY
n
23.1
120
Neurosurgery
2.1
11
Cardiac Surgery
2.3
12
Available at WLA & Sunset
55.9
290
Other
16.6
86
100.0
519
Obstetrics
Total
w
co
.,
39
Results:
An attempt was made to determine if
members who had been maternity patients at Sunset
continued to utilize Sunset for Pediatric services.
Table XI shows that 59.8% went to West Los Angeles
while 35.7% continued to come to Sunset.
Table XII displays the same kind of analysis for
utilization of other outpatient clinics by the same
population (ex-maternity patients from Sunset) .
The reason for the last two analyses was that the
f
researcher believed that once a relationship and
familiarity is established with a Medical Center, there
would be a tendency to return there if given the choice,
even when another Medical Center is in closer geographic
proximity to member.
TABLE XI
The Pediatric Facility Utilized By
Ex~Maternity
Patients From Sunset
ADJUSTED
FREQUENCY (%)
FACILITY UTILIZED
Sunset
35.7
West Los Angeles
59.8
Other Facility
3.6
Skipped
- 0.9
Total
100.0
.t:>.
0
TABLE XII
Out-Patient Facility Utilized By Ex-Maternity Patients From Sunset
_ADJUSTED
FREQUENCY (%)
FACILITY UTILIZED
Sunset
40.0
West Los Angeles
54.2
Other Facility
0.8
West Los Angeles & Sunset
5.0
Total
100.0
~
I-'
42
Results of Statistical Information
(Population Profile)
Q. 8
SEX:
Male: 42.4%
9
AGE:
18-24
:
25.44
:39.4%
45-64
:26.8%
Q.
65+
Female: 57.6%
3.1%
:30.7%
Q. 10 EDUCATION:
Number of Years:
0-8
7.7%
9-11
7.3%
HS Graduate
:18.5%
College (some)
:31.9%
College Graduate
:12.2%
Graduate Work
:22.4%
Under 4,999
: 6.2%
5,000 - 9,999
:14.5%
10,000 - 14,999
:17.1%
15,000 - 19,999
:12.8%
20,000 - 24,999
:17.1%
Over 25,000
:32.4%
Q. 11 INCOHE
Q • 12
COW1ENTS
Table XIII shows categories of comments from
members.
The high percentage of general satisfaction
TABLE XIII
Additional Comments-Coded
NEGATIVE COKMENTS
WAIT TIME
CODE
01
CATEGORY
Waiting time too long for appointments
% FREQUENCY
n
4.5
13
with personal M.D.
02
Long wait on appointment phone
9.4
27
03
Long wait in walk-in
1.7
5
04
Long wait in emergency
2.1
6
05
Long wait to see specialist
2.1
6
06
Long wait in waiting rooms even with
appointments
3.1
9
Long wait for return visits
1.7
5
07
H::-
w
Page 2 of Table XIII
TABLE XIII
(continued)
Additional Comments-Coded
PHYSICIAN CARE
% FREQUENCY
CODE
CATEGORY
08
Impersonal care
2.4
7
09
His diagnosis & incomplete treatment
1.4
4
10
Poor quality medical care
1.4
4
n
NON-PHYSICIAN CARE
11
Rude and discourteous personnel
4.2
12
12
Slow service, nurses not attentive
0.7
2
13
Bad hospital food
1.4
4
14
Impersonal care
3.1
9
15
Personnel· with language barrier-
1.7
5
cannot speak English
~
~
Page 3 of Table XIII
TABLE XIII
(continued)
Additional Comments-Coded
FACILITIES
% FREQUENCY
n
0
0
CODE
CATEGORY
16
Facilities not clean
17
Parking problems at Sunset
4.9
14
18
Facilities crowded
0.7
2
19
Dissatisfied with Sunset
0.7
2
20
Dissatisfied with West LA
2.4
7
0
0
0.7
2
COSTS
21
Dues increase too much
22
Costs too high
~
(Jl
E
Page 4 of Table XIII
TABLE XIII
(continued)
Additional Comments-Coded
BENEFITS
CODE
CATEGORY
% FREQUENCY
23
Desires inclusion of new procedures
2.1
6
24
Desires inclusion of dental care
0.3
l
0.3
1
0
0
n
HEALTH PLAN
25
Desires better member education
26
Poor claims handling by membership service
POSITIVE COMMENTS
GENERAL SATISFACTION
27
Good service-generally satisfied
11.1
32
28
Good 24 hours-7 days a week care
1.4
4
"""
0"1
Page 5 of Table XIII
TABLE XIII
{continued)
Additional Comments-Coded
GENERAL SATISFACTION (cont'd)
CODE
CATEGORY
29
Excellent care-very satisfied
30
Best possible health plan
% FREQUENCY
n
12.5
36
4.2
12
CARE AND SERVICE
31
Good professional care
5.2
15
32
Good non-physician care
0.3
1
33
Good hospital care
4.5
13
34
Satisfied with care at Sunset
1.7
5
35
Satisfied with care at West L.A.
2.8
8
~
--..)
Page 6 of Table XIII
TABLE XIII
(continued)
Additional Comments-Coded
OTHER
CODE
CATEGORY
36
Referred to Sunset by West L.A.
% FREQUENCY
n
because appointments not
available there
1.0
3
37
Access harder to West L.A.
0.3
1
38
Do not like nurse specialist program
0.3
1
39
Other specific suggestions
1.4
4
99
Not answered
MISSING
231
~
co
49
with the Program was apparent.
A Zip Code Analysis was
done to determine what percentage of the members from
each Zip Code checked "traveling to Sunset takes the
least amount of time".
The Zip Codes with the highest frequencies were:
90036
15%
90046
45.8%
90048
10.3%
Table XIV shows that both 90036 and 90048 are within
closer proximity (travel time obtained from
pre-determined lists of Planning and Support Services)
to West Los Angeles.
Even though 90046 is equidistant
from both facilities, given the choice, the members are
still utilizing Sunset.
Further analysis of responses
from members in 90046 shows that a majority (71%)
checked ".Hy regular M.D. practices at Sunset 11 •
TABLE XIV
Percentage of Members From Each Zip Code Who Thought Traveling to
Sunset Took the Least Amount of Time
CODES: 1
2
3
4
=
=
=
=
0 - 10
20
21 - 30
31 - 40
11
minutes
minutes
minutes
minutes
% OF MEMBERS THAT
: ZIP CODE
TRAVEL TIME TO SUNSET
TRAVEL TIME TO WLA
CHECKED Q. 44
90008
3
1
90016
2
1-
90019
2
1
20.0
90024
3
2
25.0
90025
3
1
0.0
90034
3
1
0.0
90035
2
1
o.o
90036
2
1
29.1
19.2
9.5
Ul
0
Page 2 of Table XIV
TABLE XIV
ZIP CODE
TRAVEL TIME TO SUNSET
(continued)
TRAVEL TIME TO WLA
% OF MEMBERS THAT
CHECKED Q. 44
90043
3
2
12.2
90045
4
2
0.0
90046
2
2
67.1
90048
2
1
23.9
90049
3
2
8.3
90056
3
2'
0.0
90064
3
1
0.0
90066
3
2
7.1
90069
2
2
15.4
90210
2
2
50.0
90211
2
1
0.0
90212
2
1
0.0
90230
2
1
0.0
U1
I-'
Page 3 of Table XIV
TABLE XIV
ZIP CODE
TRAVEL TIME TO SUNSET
{continued}
TRAVEL TIME TO WLA
% OF MEMBERS THAT
CHECKED Q. 44
90272
4
3
0.0
90291
3
2
0.0
90301
4
2
25.0
90302
4
2
0.0
90303
4
2
6.7
90304
4
2
0.0
90305
4
2
7.1
90402
3
2
0.0
90403
3
2
0.0
90404
3
2
0.0
90405
3
2
0.0
*Q. 44
TRAVELING TO SUNSET TAKES THE LEAST AMOUNT OF TIME
The percentages show what % from each of the Zip Codes had checked Q. 44.
(J1
N
Chapter 5
I.
CONCLUSIONS
A.
A significant portion of the members from the West
Los Angeles Zip Codes went to Sunset due to a lack of
specific services at West Los Angeles.
Obstetric
hospitalizations during the first half of 1977 constituted
23.9% of the total hospitalizations analyzed.
Together
with Cardiac Surgery and Neurosurgery, they constituted
27.6%.
B.
The other large majority of the member sample who
were hospitalized at Sunset had the following
characteristics:
1.
They had been with the Pr.ogr am a long time. 6 7%
had been members over 9 years.
2.
They had an established physician/patient
relationship at Sunset.
The physician/patient
relationship was the most important factor in
utilizing a specific facility, namely Sunset.
3.
The majority of those who had been with the
Program over 9 years and had an established
53
54
physician/patient relationship,were older members.
II
RECOMMENDATIONS
A.
Even though many factors bring about the
congestion of the Sunset Medical Center, the "senior"
members with long established relationships with family
physicians appear to be a significant contributing factor.
Many of these members commented that they would follow
their .M.D.'s "anywhere".
It would be interesting to see
the change in patient flow away from Sunset to West Los
Angeles if the "long-tenure" physicians transferred to
West Los Angeles provided the crucially necessary
additional space is available at West Los Angeles.
B.
When selecting sites for new facilities,
membership allocations should take into account the fact
that no matter how much closer a facility is to a member's
home, the presence of a satisfactory physician/patient
relationship will influence utilization patterns.
C.
A person's perception of geographic proximity is
not based on actual travel time but many subjective
factors as well.
D.
The issuance of color coded membership cards in
order to assign new enrollees to designated facilities
within the system may be a method of control to ensure
that utilization corresponds to member allocation.
55
III.
SUMMARY
An analysis of the hospital utlization patterns
of the Kaiser-Permanente members residing in close
proximity to the Kaiser West Los Angeles Hedical Center
revealed that 4,500 had been hospitalized at Sunset in
1978.
A survey was conducted to assess the factors
influencing the behavior of these members with regard to
medical facility selection.
Survey results indicated that the majority of the
member sample who were hospitalized at Sunset,had been
with the program a long time.
67% had been members over
9 years and had an established physician/patient
relationship.
This study can provide a frame of reference upon
which further studies can be conducted analyzing
"cross-over" utilization of facilities by HMO members
allocated to specific areas.
It is recommended that
sociological factors such as the doctor/patient
relationship and "perceived proximity" be taken into
consideration when planning new service areas.
Further studies into the utilization patterns of
members with established doctor/patient relationships
should analyze patterns for obtaining emergency care.
Do these same members utilize the facility in their
service area for emergency service even though they
56
maintain their primary physician at another facility?
true, what are the implications of this for the Program
and continuity of care?
If
57
BIBLIOGRAPHY
Abernathy, H.J. and I.L. Schrems, "Distance and Health
Service; issues of utilization and facility choice
for demographic strata." Research Paper No. 19,
Stanford University, Graduate School of Business,
1971.
Bashur, Rashid L., Charles A. Metzner, and Gary W.
Shannon.
"Some Socological Differentials in the
Use of Medical Services." Health Services Research,
6:61-75, Spring, 1971.
Kane, Robert L., "Determination of Health Care Priorities
and Expectations Among Rural Consumers." Health
Services Research, Summer 1969.
U.S. Congress, House Committee'on Interstate and Foreign
Commerce, Sub-Committee on Health and the
Environment, A Discursive Dictionary of Health Care,,
(Washington: Government Printing Office, 1976),
pp. 127-161.
Weiss, J. E. , et al.
"Determinants of r1edical Care
Utilization: the Impact of Spatial Factors."
Inquiry, 8:50-58, December 1971.
58
A P P E N D I X
59
KA!Sr:'l~
FDUNDATIDN
H05PITA1..5
4747 SUNSET BOULEVARD
LOS ANGELES, CALIFORNIA 90027 : PHONE: (213) 667·6818
March, 1979
Dear Health Plan Member:
We at Kaiser-Permanente are interested in improving the services to our
membership. To help us do this, we would like to ask you about your experiences and
utilization of Kaiser. Therefore, we are requesting that you take a few minutes of
your time to complete the enclosed questionnaire.
Your participation is strictly voluntary. Your comments will be kept confidential
and will not become part of your medical record. Your name will never be identified
with your answers. Your responses will be combined with those of other members
and the information wili only be used for statistical purposes.
A response from you is very important to the accuracy of our study, which we hope
will eventually benefit the entire membership. When you complete the questionnaire, please place it in the enclosed self-addressed stamped envelope and return it
to us.
Tnank you for your help in this important effort.
Sincerely,
~~?
RUSSELL B. WILLIAMS
V£e-President and
Associate Regional Manager
RBW:sp
Enclosure
60
KAISER
FDUNDATIDN
HOSPITALS
4747 SUNSET BOULEVARD
LOS ANGELES, CALIFORNIA 90027
April, 1979
Dear Health Plan Member:
A few weeks ago, we sent you a letter asking you to participate in a membership survey about your experiences with the Kaiser-Permanente Medical Care
Program.
Since we have not yet received your completed questionnaire, we again ask
that you spare a few minutes of your time to tell us your views about
the Kaiser Permanente Medical Care Program.
Your participation is strictly voluntary. ~our comments will be kept confidential and they will not become part of your Kaiser-Permanente medical
record. Your name will never be identified with your responses. The information received from you and other members will be combined and presented
in statistical form.
A response from you is very important to the accuracy of our study, which we
hope will eventually benefit the entire membership.
We are enclosing another questionnaire in case you misplaced the first one.
When you complete it, please place it in the enclosed self-addressed stamped
envelope and return it to us.
If you have filled out and mailed your questionnaire, please disregard this
letter.
Thank you for your help in this important effort.
Sincerely,
4!!?~~
Vice-President and
Associate Regional Manager
RBW:nv
Enclosure
61
CONFIDENTIAL
HOSPITAL UTILIZATION SURVEY
1-6/
1.
2.
How long have you been a member of the Kaiser Foundation Health
Plan?
D
1 - 4
0
5-9 years
0
0
More than 9 years
years
71
Am not presently a member
Have you ever been hospitalized in a Kaiser Foundation Hospital?
CJYES
CJNO
IF NO, please return this questionnaire in the envelope provided
since these questions will not apply to you.
8/
1[ YES, please continue answering.
3.
At which Kaiser Foundation Hospital was your most recent
hospitalization?
c:J Sunset
CJ West
Oother
(Los Angeles)
Los Angeles
(Skip to question 7)
(Skip to question 7)
IF SUNSET: please go to question 4.
3/79 NV
9/
62
4.
Why did you choose Sunset? {Check as many as apply.)
c::J I was
0
referred by an M.D. from another Kaiser Clinic.
My regular M.D. practices at Sunset:
I have been with him/her for
Years.
{how many)
10/
11/
12-13/
Oshorter waiting time to receive service.
14/
r:::JTraveling to Sunset takes the least amount of time.
15/
c:::JI like Sunset because of its layout and surroundings.
16/
r:::]I like the attitude of the personnel at Sunset.
17/
D
18/
I think the quality of care is better at Sunset.
c:::JThe facility I regularly use does not provide this service.
Oother
19/
20-21/
SA. After your most recent hospitalization, which Medical Center
have you been going to most often?
(Please check only one.;---Osunset
Owest Los Angeles
c:JOther _____________________________________
22/
IF YOU CHECKED WEST LOS ANGELES, PLEASE ANSWER SB.
SB.
I USE WEST LOS ANGELES BECAUSE:
c:::Jwest Los Angeles is easier to get to
c:::JMy family {regular) doctor practices at West L.A.
c:::Jother
---------------------------------
23-24/
63
6. What was the reason for your hospitalization at Sunset?
c:::J Obstetrics
(Maternity)
C] Gyneco 1ogy
c::J Internal Medicine
c:::J Genera 1 Surgery
c:::J Neurosurgery
CJ Orthopedic
CJ Ear, Nose.
(Non-Surgical)
Surgery
Throat Surgery
0 Urology- Surgery
0 Ophthalmology (Eye)
CJ Cardiac Surgery
Oother
25-26/
Surgery
---------------------
7 . Are you presently using pediatric services at a Kaiser facility?
DYES
CJNO
27/
IF YES. which facility do you go to for Pediatric services?
C]sunset
28/
Owest Los Angeles
Oother
---------------------
The following are for general information and will be used
for statistical purposes only.
8. Your Sex is:
9. Your Age is:
0Male
0 18-24 years
CJ 25-44 years
0 45-64 years
0 65 and over
0Fema.le
29/
30/
64
10.
Please indicate the number of years of school you have completed.
Os years or 1ess
09- 11 years
D
High School graduate
CJ Some
31/
college (13 - 15 years)
[:J Co 11 ege graduate ( 16 years )
[:J Graduate work
11.
12.
(17 years or more)
Which of the following categories best describes your total yearly
income before taxes? Please include all money that came into your
household from all sources in 1978.
0
D
$4,999 and under
D
$1o,ooo - $14,999
$5,ooo - $9,999
'
D $15,ooo
D $2o,ooo
CJ $25,000
- $19,ooo
- $24,999
32/
and over
We would welcome any additional
comments you may have about the
• , , ,..
n
33-34/
.....
WEST LOS ANGELES
MEDICAL CENTER
SERVICE AREA
0)
Lll