Kaiser, Garfield, and Permanente.

Henry J. Kaiser developed an extensive and complex industrial empire. During the construction of the Grand Coulee Dam in Washington, he began an association with Sidney Garfield, MD, that resulted in the prototype of the modern health maintenance organization. Kaiser Permanente, directed by Garfield, survived a confrontation with organized medicine in the postwar years and then expanded rapidly in the 1950s and 1960s. At the same time, an internal struggle for control and responsibility of Kaiser Permanente led to a successful reorganization of its health care system. Today, Kaiser Permanente is Henry Kaiser's most enduring legacy.

The Midpeninsula Health Service: action research using small primary care groups to provide evidence-based medicine that empowers patients while continuously improving quality and lowering costs.

OBJECTIVES: A Joint Planning Committee Report was issued in 1974 exploring how Stanford University might itself provide primary care to students, faculty, employees and their dependents at low cost. The report called for the creation of a health maintenance organization owned by its subscribers in affiliation with Stanford Medical Center. However, because the report was dismissed by the dean of the School of Medicine as being unworkable, the Midpeninsula Health Service (MHS) began operating as an unaffiliated, nonprofit health plan in downtown Palo Alto in January 1976. The MHS's planning, early operation, move to the Stanford campus, financial viability and ultimate fate are examined as an example of action research in health care. METHODS: Source documents were examined by the authors, a founding MHS board member and its two inaugural medical directors, in compiling a 30-year organizational history. RESULTS: The MHS was remarkably prescient in its early use of small primary care groups that included midlevel practitioners, the principles of evidence-based medicine, the participation of patients in self-care activities, and a commitment to the continuous monitoring and improvement of quality. Imputed annualized costs of care were 30% lower than contemporary fee-for-service care and 20% lower than that of Kaiser, with no discernible difference in health outcomes. CONCLUSION: Action research methods can be useful in identifying and testing potential solutions to vexing problems in health care delivery.

Does managed care need to be replaced? "Father" of managed care unveils new plan.

In a recent speech at the Graduate School of Management, University of California, Irvine, managed care architect Paul M. Ellwood, Jr., MD, outlined an ambitious vision for a dramatic new business model and clinical plan for health care of the future. Here's the complete text of his landmark speech, along with an update on where the plan stands today.

The history of employment-based health insurance: the role of managed care.

The author describes the history of how the employment-based health benefits system has evolved. Specifically, he examines how we got where we are today, the success of managed care, the shortcomings of the managed care system and challenges that the managed care system will face in the future. He concludes that, despite substantial improvements in the quality of medical services provided, employers have a long way to go before they are truly purchasing the highest quality health care at the most efficient prices.

A look to the past, directions for the future.

This article represents the history of primary care and behavioral health integration at Group Health Cooperative (GHC) over the last decade, and foreshadows probable futures for this work into the next decade. To build from a logical progression, the article responds to a series of questions: 1. Why integrate primary care and behavioral health? 2. What has been done so far and how well has it worked? 3. Keeping the end in mind, what's the idealized picture of integration for the future? 4. How to get from here to there? What will help or hinder the effort? and 5. Again, why make these efforts to integrate?