After living through two years of a pandemic, access to quality health care has become more important than ever before. This is why it’s unusual—and refreshing—to learn about health care companies that put people over profit. One such company in the Northwest U.S. stands out for its efforts to incorporate innovative thinking in its everyday operations while operating with a unique physician-ownership structure.
Northwest Permanente is an independent, physician-led medical organization that also happens to be the largest medical group in Oregon and Southwest Washington. Providing integrated care in partnership with Kaiser Foundation Health Plan and Hospitals, Northwest Permanente employs more than 1,900 clinicians and administrators who act as leaders in a clinical care setting and in their communities. Since Kaiser Permanente was founded, the program has made decisions guided by what’s best for their members and the communities they serve. Today, Northwest Permanente continues to commit to making measurable improvements in its environmental and equity practices and policies.
I recently talked with Doctor and Medical Director of External Affairs, Government Relations and Community Health Colin Cave as well as Director of Corporate Social Responsibility and Communications Perry Jaqua about how they are taking sustainability seriously at Northwest Permanente. “We want to support doctors doing the right thing,” Cave says. “It feels good that we belong to a company that will.”
In the following conversation, they share with me some of the tangible ways they have worked to become a sustainable health care company. This includes incorporating transparent practices with patients and staff, supporting the mental health of their physicians and administrative staff, and even reducing greenhouse gas emissions by transitioning to telehealth visits.
Colin Cave: Northwest Permanente is actually the oldest of all of the Permanente Medical Groups, and it began as a very small group of just seven physicians. In the early 1940’s, industrialist Henry J. Kaiser and physician Sidney R. Garfield worked together to provide the first-of-its-kind prepaid health care in the nation to employees. Back then it was almost unheard of, and it was not what doctors were used to. But Dr. Garfield, realizing that injured employees can’t work efficiently, told companies he’d come in and cut their costs while keeping their people safe and healthy, and preventing injuries.
Northwest Permanente is a professional corporation, so it has to have a majority of physician shareholders, and it used to just be physicians in the strictest sense of the word. We expanded it to include podiatrists decades ago. As part of our core work, we realized expanding ownership was a good thing to do, and we had to do that within the realm of being a professional corporation. We have expanded ownership now to other groups of clinicians. We are also most proud that Northwest Permanente is the first physician-led medical group in the world to become a Certified B Corporation. We are still the largest medical group anywhere that is a Certified B Corporation, so we take great pride in that.
Marquis: Many companies have talked with me about how much they learned during the process of becoming a B Corp. Were there any specific challenges you faced seeking certification given your structure and focus on health care?
Cave: I think that when we first learned about B Corps, we realized we were already — at our core — a B Corp. We just weren’t yet certified. Going through the certification process was a way for us to formalize much of what we were already doing. And it allowed a lot of good things to happen.
Perry Jaqua: When you look at our B Corp peers, a lot of companies are doing great work. So for us, the whole process was validation that we were walking the walk, not just talking the talk. When you specifically look at us against other medical groups, becoming a B Corp helps us effectively communicate how we handle some matters differently. For example, when we talk about a shortage of physicians, we can actually say we are doing our best because we are continually innovating and evolving, and we want to have like-minded people join us.
Cave: Yes, we’re going through the B Impact Assessment (BIA) now. Perry leads those efforts; she’s a wealth of knowledge on all of this. And I think, going back to what we learned throughout the process, we found that we needed to share what it is we do more publicly. In doing that, I think the BIA did us a great favor because it allowed us to be more transparent and show off what we were already doing. New graduating physicians are looking for something more than just great pay. This newer generation of physicians care just as much about belonging to an organization with a purpose as they care about all those other things. And while it can be hard to bring in certain specialists and primary care physicians across the board, becoming a B Corp and being transparent in what we do has helped us gain the attention of people who are looking for a mission on top of a place to work. It’s been great, and we believe it has helped with retention, too.
Jaqua: Honestly, I feel like this is a place where people choose to be. They don’t just end up here.
Cave: The major challenge for us is that the Kaiser Permanente program is made up of Kaiser Foundation Health Plan and Hospitals, which is centered in Oakland, California, and is a not-for-profit, and all of the Permanente Medical Groups, each of which is an independent professional corporation. Together, these entities form what is commonly known as Kaiser Permanente (KP). We are one of the Permanente groups. We are for-profit and the only Permanente Medical Group that is a B Corp.
Now here’s why this matters. All the hospitals, all of the facilities, all of the office buildings, all the clinics, and all of the administrative buildings are owned, operated, and run by the Health Plan organization — again, a not-for-profit. So the Scope 1 and 2 emissions — or the emissions generated in these buildings and by generating the energy needed to run these buildings — are attributed to the Health Plan. We as the clinicians and administrative staff work in these buildings, but we don’t own, lease, rent or operate them. So we as Northwest Permanente can’t get “points” on the assessment for any building-related mitigation efforts. Northwest Permanente is therefore fully a Scope 3 business, and that is a challenge in showing our true environmental leadership on the BIA.
Marquis: What kind of changes have you implemented to enhance the organization’s positive environmental impact?
It’s incredible that Kaiser Permanente is the first health care organization in the United States to become carbon neutral for Scope 1 and 2. Even though we don’t have Scope 1 or 2 attributed to us at Northwest Permanente, we work in those buildings and can have a positive impact on those emissions through smart medical practice. Kaiser Permanente is really leading on the environment.
We understand the importance of this. For the past two decades, it’s been the hospital administrators who have created organizations like Health Care Without Harm and done so many things to create greener buildings, and it’s only been in the past few years that we’ve actually seen physician leadership move into this space. Physician leadership is so important right now because we as physicians understand how important clear air and clean water are to health. So we’re stepping into that space. Even though our business model makes it so we can’t score as highly on the BIA, in some respects this encouraged us to say that we didn’t care what the score was. We’re going to be leaders. And we started with the first Climate Action Plan for any major medical group. We followed with extensive environmental guidelines. We were the first to publish a large-scale study showing the positive environmental effects of reducing the commute from patients using virtual visits. That’s all clinician-led work. Our telehealth visits can actually help reduce greenhouse gas emissions and costs. We are also leading by changing anesthetic gasses from desflurane to sevoflurane and instituting operating room policies that have significantly reduced medical waste and emissions. Thus, we as clinicians can and do mitigate the Scope 1 and 2 emissions in the buildings in which we work.
Jaqua: I think you’ve nailed it, Colin. The work we’re doing pushes us to do better and be more innovative. The work that Colin did with the carbon intensity study, for example, was pretty groundbreaking. So when we think about physician leadership, it’s important to think about the future population of physicians and health care. We want like-minded people who share our values to fill these leadership roles. That is what will make a difference in the future.
Cave: As we moved further through our BIA, we became more cognizant and more intentional in making sure not only our physicians, patients, clinicians, and administrative staff are taken care of. We care about the dignity and the importance of a living wage job for those people in our communities. We want to create healthy communities.
I’ve been honored to join to the KP Impact Spending Advisory Council, with the goal of helping to direct billions of dollars of purchase power toward companies in our communities owned by women and people of color. Improving the financial health of our communities will ultimately improve the physical and mental health of our communities by providing living wage jobs and opportunities for improved living conditions. So we’re taking health into account at every level. This is led by Kaiser Permanente nationally, and it is humbling to work with such dedicated and passionate leaders who care deeply about their communities.
Marquis: I’d love to learn more about how Northwest Permanente serves its community. How do you reach out and work with traditionally underserved communities to increase their access to health care?
Cave: Oregon is a state that’s had a low rate of uninsured people for a number of reasons, such as the Oregon Health Plan and the Affordable Care Act (ACA). That said, not everyone could qualify for insurance. People who are not citizens, for example, may not have qualified. Over the course of a few years, we were able to throw our support behind two initiatives – Cover All Kids and then Cover All People – that now allow these individuals to access quality health care. Our leaders testified in support and our government relations teams put their weight behind passing these groundbreaking measures.
But even with all of that, there are still people that can’t come in to get care for whatever reason — many can’t take time off work to be seen by a physician. Northwest Permanente has a strong partnership with Virginia Garcia Memorial Health Center, a local Federally Qualified Health Center (FQHC). During the summer harvest seasons, many of our Spanish-speaking physicians have worked with Virginia Garcia staff to volunteer at work camps to help provide workers with the care they need. We have free-clinic partners from Longview, Washington, to Springfield, Oregon, where our physicians will care for patients during an annual service event. Our primary care physicians who serve at these clinics have full access to our specialists as needed to provide real-time, virtual consults. Northwest Permanente covers the cost for these shifts because we want to support doctors doing the right thing, and it feels good that we belong to a company that will.
Led by many of our own physician leaders of color, we have also organized community vaccination clinics to immunize local underrepresented communities – those who have been most affected by the pandemic. We’ve worked with our Health Plan partners to roll out Thrive Local, which is our community resource locator. It’s one of the first of its kind in the country, in fact. We set it up and we’re sharing it with the entire state of Oregon. It will help not just Kaiser Permanente members, but everyone in our communities find links to vital services they need.
Our membership has grown, which means our in-person clinic visits have increased as well. But we found our virtual visits were increasing at a higher rate than our in-person visits — even before COVID-19. Our use of virtual visits has been on the leading edge. During the pandemic, when hospitals were overflowing, we were able to use technology to move hospital-level care into the patient’s actual home. One of our main concerns was that this service might leave low-income communities behind because of a lack of broad band or resources. But it turned out to be the opposite. We were able to set up all needed technology in these homes, provide the needed broadband connection and arrange for monitoring and home visits. At the same time, we were able to directly determine the gaps these households were experiencing and get them connected to community resources that they needed. It turns out our hospital at home program has actually helped people in low-income communities more than in other communities. So there’s a lot of ways that we continue to be innovative in who we can care for and how.
Marquis: How has Northwest Permanente helped to advance gender equity by encouraging more women to become physicians?
Cave: Personally, I raised one. She's in her second year at the Mayo Clinic. But in all actuality, there are a limited number of residency spots. Expanding the number of spots is not something we have control over, even if it’s something I think we need to do. However, we do have control over making sure everyone gets paid the same — at Northwest Permanente, there’s no pay gap, and there’s no leadership gap. Our board is two-thirds women, and our CFO, our board chair, and our COO are all women. So when you ask what we’re doing, I think the most important thing you can do is to let the women you hire know that they are valued and equal partners in every sense of the word, and then influence other groups to do the same. Women getting into medicine know that it is still very much a male-dominated field in many parts of the country. We need to dismantle that, and I think we’re leading by example.
Jaqua: Last year we hosted a three-day national conference for women and their allies in medicine, focused on the unique needs of women physicians, and we welcomed women medical students as our guests. One of our core values is inclusion, and, as Colin said, in our actions we constantly reinforce the message that all are welcome at Northwest Permanente.
Marquis: What about efforts to improve diversity and inclusion?
Cave: One of our core stated values is inclusion, and we take it to heart. The National Medical Association was created by and for physicians of color back when the American Medical Association would not allow physicians of color to join. Oregon did not yet have a chapter, and one of our board members wanted to create one in Oregon. So Northwest Permanente put together a group membership for physicians of color and their allies. They are now reaching out to the other medical groups in town to seek wider participation. We want it to feel like a community where our physicians feel like they belong and where they have the power to do something good for other physicians, students, resident physicians, or medical students of color. The goals include creating mentorship, a sense of community and medical scholarships as well. Northwest Permanente has also established middle school programs and summer internships to support students of color interested in pursuing a medical degree.
Marquis: The last few years have been really stressful for people in the health care professions. Particularly during that first wave of COVID-19. With so much stress and uncertainty, what did you do for your own workers to support their mental health and well-being?
Cave: As a frontline physician, I really appreciate this question. It was a scary time. Heading into the pandemic, we made sure all our decisions were physician-led. There wasn’t anything that wasn’t science-based. We never let anyone feel like they were being “sacrificed” because they had to do something unreasonable. We were all in this together. So, in addition to having great leadership, we made sure to have great communication. We communicated daily about what was happening in the hospital: how full we were, what the positive test rate was, what the PPE supplies were and so forth. We made sure everyone was on the same page, from the physicians and hospital administration staff that walked into the hospital to the medical groups in our outpatient clinics. Transparency was very important.
We also offered peer support groups with specially trained physicians. We had mental health resources through our Permanente Advocacy Resources (PAR) program, able to provide a sense of both safety and privacy. We provided childcare stipends for physicians who couldn’t send kids to school, and held department debriefs to allow people to be heard. We were constantly learning and then making improvements based on what we learned.