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express our appreciation to all those who have worked with us, our trustees, our physicians and fellow workers, our health plan members, the medical societies, civic and union leaders, and the fair opposition. Opposition to change is natural and healthy; the effect of this opposition was to stimulate us to do a better job.

[From the New England Journal of Medicine, October 30, 1952]

THE PERMANENTE PLAN'S FIRST 10 YEARS

With the cost of medical care rising progressively, with insurance plans such as Blue Cross and Blue Shield forced to increase their premiums while their benefits provide for decreasing proportions of the faster rising costs, and with less and less of the worker's income from wages or salaries available for savings, it is a question whether the supplying to considerable segments of the people of some form of prepayment plan for total medical care can be indefinitely postponed.

Details of the plan are worthy of study, for, although Dr. Garfield's presentation might be interpreted as being tinged with enthusiasm and self-interest, the facts of its accomplishment are impressive. It has also been a financial success. In the 10 years since the plan was established and while it was developing, participating physicians and professional personnel have been paid $23.5 million, and over $10 million has been paid to nonprofessional personnel and $1.5 million to outside physicians and professional people.

The organization consists of the following parts: a foundation that is a charitable trust providing facilities and funds for teaching, training, research and charity; a health plan that enrolls members, collects funds and apportions them among the hospitals, medical groups and administration; hospitals that are nonprofit corporations operating medical centers; and medical groups of independent physicians organized in partnerships, each covering a regional service area. The incomes of the doctors in these groups compare favorably with those of physicians in private practice in the same area.

In closing his report Dr. Garfield makes the following statement of the future and of the aspirations of the Permanente plan:

We are striving to prove (1) that high quality medical care and hospital service can be rendered to the people at a cost which they can afford; (2) that this can be done to the benefit of all parties concerned-the people, the physicians, the hospitals; (3) last and not least, to prove that all this can be done by private enterprise without necessity for government intervention. *

* The great interest displayed by doctors, labor, government and the people in the Permanente idea encourages us to believe that the accolade of "mission accomplished" cannot be too far off. The workers at Permanente feel that new horizons are opening up for the coming decade. * * *

* The lifting of barriers to the financing of facilities, as demonstrated by the projected new construction, cannot help but make an impressive demonstration to the physicians and hospitals of the country. The excellence of these new facilities, their innovations, the quality of work being performed, the educational and research programs developed will add in no small measure to pyramiding evidence of worth and soundness.

Certainly, this plan is worthy of careful study by physicians throughout the country as one type of program that may not only erect further defenses against the encroachment of socialized medicine but actually provide more and better medical service, at lower cost, and at the same time maintain the dignity of both doctor and patient.

In the 10th anniversary issue of the Permanente Foundation Medical Bulletin,' issued in August 1952, Dr. Sidney R. Garfield traces the development and growth of the Permanente plan in the Pacific coast States. It was originally designed to meet the serious dearth of facilities and medical services in the San Francisco Bay area created by the mass dislocation of people into wartime shipbuilding. Actually, it evolved as the result of a decade of earlier attempts by a group of interested and far-seeing persons to provide the best hospital and medical

1 Garfield, S. R. Report on Permanente's first 10 years (Permanente Found. M. Bull. 6:1-12, 1952).

care to average workers at a cost that they could afford. According to its director, the plan, as it actually worked out, was the outstanding wartime medical service outside the Armed Forces; the list of its achievements seems to bear out that estimate.

At the end of the war in 1945, when shipbuilding was discontinued and the workers were dispersed throughout the country, the relatively few who remained served as a nucleus for the continuation of the plan on a community basis. Now, in 1952, the Permanente plan serves 250,000 members in California, Oregon, and Washington, as well as large numbers of patients who are not members. The acceptability of the plan and its popularity are fully attested by the fact that new facilities are now under construction that will provide for an increase in membership to 400.000.

The scheme was designed to eliminate the waste resulting from poorly planned facilities and from the ineffectual coordination both among the physicians themselves and between them and the institutions in which they worked. It was accomplished by a well-coordinated group practice operating in well-planned medical centers. It is a prepayment plan based on the insurance principle for the provision of a comprehensive medical service. The fee for service was abolished, but all the prepaid funds have been going to physicians and hospitals. It has apparently been a successful experiment, designed to provide complete medical care of the highest quality to large groups of people at a cost that they can afford and that they can budget. One experiment deserving such scrutiny is the Permanente plan.

[From San Francisco Chronicle, August 20, 1953]

KAISER'S DREAM HOSPITAL TO OPEN IN WALNUT CREEK

(By Milton Silverman, Science Writer, the Chronicle)

The hospital that couldn't be built-a medical dream house for doctors, nurses, and especially patients-will be opened for public inspection Sunday at Walnut Creek.

It's the $2 million, 94-bed Kaiser Foundation Hospital to serve eastern Contra Costa County.

Built like a rambling ranchhouse in a 7-acre garden, it is an air-conditioned, electronically operated structure in which practically everything works with pushbuttons, including the bedpans.

Almost every phase of the new hospital represents a revolution in hospital design, a revolution long urged by patients and staff members.

8 O'CLOCK WAKING

When the hospital opens officially next month patients will not be awakened at 5 a. m., or some other ghastly but standard hour, but at 8 o'clock.

Instead of being greeted with a cold washrag in the face and a thermometer in the mouth, they can start with coffee and toast. Each room is equipped with its own electric coffeemaker and toaster, within arm's reach of the patient.

Each room is also equipped with a wash basin, running icewater, a radio with a choice of four stations or a phonograph, a telephone, a pushbutton to raise or lower the head or foot of the bed, and a closet, all within arm's reach. A patient will not have to clamber out of bed to get a drink, a bathrobe, or a lipstick.

LANAI OUTSIDE

Each room opens out to a lanai, or veranda, through sliding glass doors. The doors can be covered by sliding drapes which the patient opens or closes by a pushbutton.

In the obstetrical wing an ingenious arrangement is used to move the baby in and out of its mother's room, giving all the advantages of the living-in system but none of the disadvantages.

When the mother wants the infant near her she pulls a contraption like a stainless-steel file drawer, and out slides the baby's crib next to her bed. When the baby is scheduled to return the file drawer is pushed back and the baby rolls into its own private, air-conditioned nursery.

A separate nursery is available for premature infants.

FATHERS' ROOM

Expectant fathers will also have their own room, equipped with free hot coffee and cigarettes.

Planned by Dr. Sidney Garfield, medical director of the Kaiser Foundation, the new hospital has everything designed for the comfort of the patient.

The price for private rooms will be $20 a day, while semiprivate rooms will cost $15.50 to $17.50 a day, substantially lower than the price charged by many oldfashioned institutions.

Hospital officials claim the cost is being kept down by one part of the institution which few patients, and none of their visitors, will ever see. This is a long inside corridor running the length of each wing, and divided into streamlined units for each nurse, units which look like a cross between a new railroad compartment and the control room of a modern television station.

NURSE'S POST

Working at her post, each nurse will be in charge of eight patients. "There is no need for her ever to go to another part of the hospital while she is on duty," Dr. Garfield claims. "She will always be near her patients."

Each nursing post, contains a desk and filing compartment for records, charts, X-ray photographs, medicines, food trays, and fresh linen for each patient. There are also telephones, intercoms, red lights, green lights, yellow lights, and other assorted signaling devices.

If the nurse needs drugs, these are delivered to her through a pneumatic tube. If she leaves her desk to take care of an emergency with one of her patients, she pushes a button which sounds alarms in adjoining nursing stations.

NURSES LIKE IT

"We've already tried this system in our new hospital in Los Angeles," says Dr. Garfield. "It seems to work efficiently, it gives each patient more nursing care per day, and per dollar, than any other system, and the nurses seem to like it, too. They spend their time nursing, not running all over the hospital like errand boys."

Hospital officials announced the building will be open to public inspection from this Sunday, August 23, through the following Sunday, August 30. Visiting hours will be from 1 to 9 p. m. on each Sunday and on Saturday, and from 5 to 9 p. m., Monday through Friday.

DOCTORS INVITED

All doctors of east Contra Costa County were invited to a private preview showing from 1 to 9 this Saturday.

When the hospital opens for routine operations, it will be open to patients of all qualified physicians in the area.

"It has been built to bring the newest and best in modern hospital facilities to this rapidly growing suburban area," Dr. Garfield said. "We hope it can help bring better health to our new neighbors."

[From American Journal of Public Health, vol. 42, No. 12, December 1952] MULTIPHASIC SCREENING OF LONGSHOREMEN WITH ORGANIZED MEDICAL FOLLOWUP1

E. RICHARD WEINERMAN, M. D., M. P. H., F. A. P. H. A.; LESTER BRESLOW, M. D., M. P. H., F. A. P. H. A., NEDRA B BELLOC; ANNE WAYBUR; AND BENNO K. MILMORE, M. D., M. P. H., F. A. P. H. A.

Medical consultant, San Francisco Labor Council;' chief, bureau of chronic diseases, California State Department of Public Health; associate statistician, morbidity research project, California State Department of Public Health; health educator, International Longshoremen's and Warehousemen's Union

1 Presented before the medical care section of the American Public Health Association at the 80th annual meeting in Cleveland, Ohio, October 22, 1952.

At time of survey, medical director, Permanente Health Plan.

On leave.

Pacific Maritime Association Welfare Fund; and acting chief, bureau of chronic diseases, California State Department of Public Health and senior surgeon, United States Public Health Service; San Francisco, Calif.

In the past few years multiphasic screening has become a widely accepted procedure for the early detection of unsuspected disease among apparently healthy people. The combination of many different technical and laboratory procedures for mass screening grew out of the successful single-shot case finding programs for syphilis, tuberculosis, and, more recently, diabetes. Large-scale projects in many communities have demonstrated the feasibility of multiphasic screening as a public health technic.

Not previously investigated, however, has been the potentiality of multiphasic screening in medical care programs providing comprehensive services. As a method of preventing unnecessary complications of disease and of promoting the economy and effectiveness of medical service, the multiple testing procedure should offer many advantages to medical care organizations and to health-conscious consumer groups.

The decision of the International Longshoremen's and Warehousemen's Union and the Permanente Health Plan to organize a multiphasic screening program afforded a unique opportunity to study:

1. The results of medical followup of multiphasic screening when there was no charge to the individual participant for diagnostic and treatment service, and when all records were available through one medical care organization. 2. The costs of the screening tests and of followup services.

Special characteristics

ORGANIZATION OF THE PROJECT

Three features characterized the program as developed for the longshoremen in the San Francisco Bay area. First, a well-organized consumer group-the union-took the initiative in instituting the project and assumed a large share of the responsibility for its preparation and organization, thus providing the best possible foundaton for a successful public-health enterprise. Second, through the medium of a joint labor-management welfare fund, the workers were covered for comprehensive medical care under a prepayment plan which maintains group medical center facilities throughout the bay area. Thus, no financial barriers to complete follow-up of positive test findings faced the individual longshoremen, and one difficult problem of mass screening could be avoided. Third, a wide array of public and voluntary health agencies in San Francisco actively participated in the planning and conduct of the case finding endeavor. In this way, costs were spread, the scope of service was extended, and widespread community interest and support were developed.

Numerous special problems had to be solved. A group of skeptical workers scattered over 80 miles of waterfront had to be persuaded to travel to the union headquarters and undergo a battery of strange-sounding tests, often missing thereby a day's work. Many of these men had been unaccustomed to regular medical attention and were suspicious of health examination procedures because of their misuse in employment practices in the past. The workers represented many cultural and language groups and every level of education. The summer vacation period, plus heavy work schedules, added to the difficulty of getting the longshoremen to the test station. Men with positive tests had to be referred to one of several medical centers. Finally, the very proper insistence of the union on protecting the personal privacy and job security of its members necessitated special efforts to maintain the confidential nature of all records. Educational campaign

One early lesson of the project was that the educational campaign among the workers became effective only when the union itself assumed responsibility for disseminating information about the health tests and encouraging members to participate. As the regular channels and procedures of the union were opened up, the workers themselves-using familiar language and accustomed approaches-carried on the campaign.

The union health committee of rank and file members assumed the main responsibility, with assistance from a full-time staff worker assigned by the

The International Longshoremen's and Warehousemen's Union-Pacific Maritime Association welfare fund.

welfare fund and with technical guidance provided by a committee of professional health educators. Work priority was guaranteed to all men who lost job time because of participation on the health committee.

The committee utilized every possible aspect of usual union routine and invented some ingenious new techniques. The program was discussed at membership and officers' meetings; all regular publications of the union were used and a special health test bulletin issued; leaflets and posters concerning some of the diseases detectable by the tests were widely distributed on the waterfront and at the pay windows. Leaders of each work gang surveyed their members and reported to the committee on the levels of information and acceptance. A special mailing to each member's home, including a union-devised pamphlet entitled "Are You Shipshape?" preceded the opening date.

A fairly level rate of participation was maintained throughout the actual testing period by the continuous efforts of the union health committee. Members who had completed the tests wore special health test buttons. A prominent health test stamp placed in the union book of each man tested enabled gang stewards to check the members regularly. The entire machinery of the hiring hall and the dispatching system was utilized to encourage maximum participation: work gangs were actually dispatched to the tests according to a schedule; loudspeaker announcements were made regularly in the hiring hall; job dispatch slips were stamped with a health test reminder; and careful records of response were kept with followup letters sent to leaders of delinquent gangs.

Progress reports were prominently displayed so that the entire organization was stimulated to establish the best attendance record possible. As a result of this educational effort, some 4,000 out of an estimated 5,200 eligible and available members presented themselves for testing during the 7 weeks of the project.

Organization of the screening program

The testing facilities were established on the second floor of the union hiring hall on the San Francisco waterfront. The union supplied furnishings, and technical equipment was provided by the Permanente Health Plan and the various cooperating community agencies. Permanente and the labor-management welfare fund defrayed expenditures for payroll and supplies. The statistical analysis phase of the program was conducted by the State department of public health.

Eight public and voluntary community agencies provided equipment and personnel for the testing program. Table 1 summarizes these contributions. Under the overall direction of the medical director of the Permanente Health Plan, a committee of representatives from each of the participating agencies met frequently for the determination of general policy. The working staff consisted of 2 administrative supervisors, 12 full-time and a variable number of part-time and volunteer technicians, 5 clerks and a union volunteer group which maintained traffic control and assisted in general maintenance. A carefully designed record system facilitated the followup and the statistical evaluation of the project.

Men with positive test results were referred to the Permanente medical center nearest their homes, being given appointments either for confirmatory laboratory procedures or for appropriate medical visits. Further letters were sent and phone calls were made to nonresponders in a concerted effort to attain maximum medical followup. Thus 72 percent of those with positive test results responded for medical followup within 4 months after the tests were concluded. TABLE 1.-Contributions by Participating Community Agencies to Multiphasic Screening of Longshoremen, San Francisco, 1951

California Bureau of Vocational Rehabilitation

Provided trainee personnel for clerical and semitechnical work in testing program.

California State Department of Public Health

Provided consultants in organization, health education, statistical, and laboratory technics; performed serologic tests for syphilis; loaned Clintron blood sugar equipment: provided audiometry personnel and equipment; provided health education materials; prepared statistical analyses.

California State Harbor Commission

Renovated premises and installed special electrical wiring system.

San Francisco City and County Health Department

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