Last in a series
The story of Kaiser Permanente in Southern California could not be told better than through the life and career of Sam Sapin, a pediatric cardiologist who joined the medical group in Los Angeles in 1955. Sapin, a New York City transplant with a slight accent reminiscent of his roots, could have had a lucrative career taking care of wealthy patients in his native city. He had a thriving practice on Park Avenue before choosing to migrate to California.
He was lured to Los Angeles after hearing from friends about an innovative, albeit fledgling, group of doctors with a philosophy quite different from his fee-for-service colleagues in New York. Rendering proper and compassionate care to patients without having to consider their ability to pay sounded good to Sapin. So good, in fact, that after one brief visit to the West Coast, he and his wife, Jean, with their two small children, picked up and moved.
In the course of six decades associated with KP, Sapin has seen unimaginable changes, played many roles and helped to nurture the health plan’s phenomenal growth in membership, reputation, and influence in Southern California and in all its regions.
He’s had his hand in establishing and expanding programs in physician and patient education and research; he’s been influential in the creation and refining of quality assessment and improvement systems; and he’s been a trailblazer in KP efforts to ensure appropriate use of medical technology.
Sapin received an Excellence in Medical Education Award in 2011 from the Thomas F. Godfrey Center for Medical Education. He was honored for his lifetime achievements, especially in promoting physician education.1 In presenting the award, retired director of the center and fellow pediatrician KP Rudy Brody said: “Over the years no one has done more for Kaiser Permanente to advance medical education, research and quality than Sam.
“He was co-founder in 1955 and a long-standing member of the Southern California Permanente Medical Group's (SCPMG) Pediatric Symposium Committee (which celebrated its 50th symposium in 2008). Most importantly, Sam was a member of the Center for Medical Education’s Advisory Committee (1999 to present) that guided the center through its initial years.”
These accomplishments are really just frosting on the cake for Sapin whose main career focus has been to take care of newborns and older children with heart problems. His decades-long efforts in this realm have entailed finding groundbreaking ways to repair congenital problems so his often tiny patients could live healthier and sometimes completely normal lives.
As KP physicians have always been encouraged to do, Sapin quickly associated himself with academia and conducted and published research throughout his career, as recently as 2005.
“Shortly after I joined the group I applied for a teaching appointment at Children’s Hospital, just across the street, but I was never accepted, nor rejected, because I was one of those ‘Kaiser’ doctors,” Sapin said recently. “I then drove across town to UCLA, where I was welcomed, became an assistant professor of pediatrics in the Division of Cardiology, and eventually, a clinical professor.
“I was able to take our pediatric patients to UCLA, perform cardiac catheterizations, and have their cardiac surgery done there. In 1957, Pete Mahrer, Mt. Sinai trained (as Sapin was), joined our group. 2 The two of us set up a small cath (cardiac catheterization) lab at Sunset (KP Los Angeles Medical Center). The equipment was kept in a closet and rolled out into an X-ray room when available.
“We put on our red glasses half-hour before the procedure, to be able to see the fluoroscope in the dark. Pete helped me with the pediatric cases, and I helped him with the adults,” he said. In 1960, a diagnostic cardiac catheterization laboratory for pediatric and adult patients was opened at Panorama City, and Sapin served as director until 1982.
Sapin took on administrative duties when he became the chief of pediatrics at Panorama City in 1959. But he didn’t give up his practice, a decision he never regretted. “Fortunately, for me, I was able to practice until I was fully retired in 2000."
As chief of pediatrics, Sapin founded the first Kaiser Permanente nurse practitioner program in 1964 and at one point oversaw the training of nurse practitioners. He held the chief position until 1972 when SCPMG Medical Director T. Hart Baker appointed him regional director of the Department of Education and Research, a department created to manage the growing education and research programs funded by the Community Services Fund.
In accepting his lifetime achievement award last year, Sapin recalled: “Seeing patients was very gratifying. On the other hand, my administrative career could sometimes be frustrating. Physicians, who’ve been trained to be problem-solvers and independent operators, can be resistant to change.
“Let me read to you, from a brief memo, which Dr. T. Hart Baker, our medical director at the time, sent out to doctors in May 1972:
“‘Dr. Sam Sapin has been appointed director of Research and Education. . . The location of his office and his telephone number will be forwarded to you as soon as a suitable location is found.’
“What I’d like to read to you now is the comment of some anonymous person — presumably a physician — who sent the memo back to me with the following suggestion scribbled on the back of it, in red ink, about a suitable location for my office, it read: ‘On Edgemont, behind garage at 1226 apartment house — go thru back yard, but beware of German Shepherd dog. (Go) up to second story — above chicken coops — and past the old EKG labs.
“Turn left, then right, knock twice and say Marshal. If a short fellow scratching his cheeks answers, turn back, you’re in Fontana! P.S. Dress at this office is casual — jeans and old shirt — since only orange crates and dirty Zolotone boxes are available for desks. Boots are a must, until the exterminators are through. Bring your own Xerox machine, since our last one fell through the loose floorboard. Also, a cheerleader’s megaphone will come in handy for long distance calls.”
In 1982, newly appointed SCPMG Medical Director Frank Murray founded another new department — the Department of Clinical Services — which subsumed Sapin’s responsibilities concerning research, education and quality. Murray appointed Sapin associate medical director of Clinical Services, which soon included divisions of research, staff training and medical manpower, quality of care, quality of service and appropriate use of technology.
In 1983, Sapin beefed up KP Southern California’s preventive medicine program by requiring each medical center to offer a core health education curriculum addressing chronic conditions and healthy lifestyle issues. Also as Clinical Services leader, Sapin formalized the Inter-Area Chiefs of Service Groups and required chiefs in all specialties to convene four to six times a year. “I thought this structure was essential to assure the delivery of a comparable quality of care throughout the region.”
By 1990, Sapin had served on the SCPMG board of directors for 16 years, as an elected representative from 1957 to 1966 and as a regional associate medical director from 1982 to 1990. He had won the respect of his physician colleagues and the adoration of his patients. In his last years before retirement from the medical group administration, Sapin had several invitations to size up his career and the changes he’d seen. One such opportunity was to speak before the annual meeting of the American Group Practice Association in Minneapolis in 1989.
Rather than speaking just from his perspective, Sapin surveyed his SCPMG colleagues and presented the results in his talk titled “Managed Care — What Works in Groups.”
The survey identified six KP success factors: 1) integrated care design with doctors making medical decisions and KP owning its own hospitals; 2) people with a social purpose and ethics, commitment to high quality and peer review; 3) innovation, long-term planning, nonprofit financing plan, comprehensive care and affordable rates.
Sapin’s list continues: 4) ability to control costs due to ownership of facilities, purchasing power and physician extenders (nurse practitioners, etc.); 5) support from labor, business, academia and government; 6) reputation as a strong organization that is always there to provide care for significant illness.3
Sapin, a tireless KP defender and passionate believer, summed it all up for his audience: “The right people with a good idea at the right time.”
In 1992 when health care reform was hugely topical and Sapin was retired and consulting for Clinical Services, KP quality leader Sharon Conrow asked him to draft what he thought Kaiser Permanente’s reform position should be. Sapin didn’t hesitate.
“I said, one, I think it should be a single-payer system . . . eliminating the fee-for-service idea. That it would be essentially the model that we have now, but with (ways to address) some of the things we had problems with. For example, when it comes to new technology, what should we invest in?” Sapin recounted recently.
“Now (2012), my recommendation for reform is to duplicate the Kaiser Permanente model. That’s what I’ve been saying. The more I’ve been looking and thinking about this, and all these intrinsic, built-in things that make us have to provide better care based on all the evidence, and so on, (the best structure for effective reform) is the model that we’ve built.”
Kaiser Permanente is the one and only health maintenance organization (HMO), the only managed care organization that fits the original and the current HMO definition, Sapin says. As conceived in 1971 by Paul M. Ellwood, Jr., famed health policy expert, an HMO consists of a multi-specialty group practice whose doctors contract with a nonprofit health plan to take care of patients on a prepaid basis.
Ellwood, who has influenced national health policy over the decades, is frustrated by the lack of progress on the health reform front. He said he originally intended HMOs to be nonprofit entities and to include structure to ensure accountability for quality of care as well as to contain costs, the main objective in the early 1970s as well as today.
“What went wrong?” Ellwood asks rhetorically in his 2011 oral history. His answer: “Political expediency in the initial plan designed to promote HMO growth led to the inclusion of three mistakes: for-profit plans, independent practice associations, and the failure to include outcome accountability.”
Ellwood’s sad assessment gives credence to Sapin’s argument that KP stands out as the model. Ellwood says of Kaiser Permanente and its pioneering physician Sidney Garfield: “Sid Garfield’s plan is 80 years old but it is still the gold standard.”4
1 The Center for Medical Education was founded at the KP Los Angeles Medical Center in October 1999. The center offers continuing education, residency and fellowship programs and rotations for residents and fellows from nearby medical schools. Its advisory committee draws members from the community as well as SCPMG.
2 Sapin earned his MD from the New York University College of Medicine and completed a rotating internship at Mt. Sinai Hospital and his residency in internal medicine at the U.S. Veterans’ Hospital, both New York institutions. He took his internship in pediatrics at Bellevue Hospital in New York and his residency in pediatric cardiology at Mt. Sinai Hospital in New York City.
3 “Managed Care — What works in groups 1989 — A case study of successful HMOs,” Samuel O. Sapin, MD, presented at the Annual Meeting of the American Group Practice Association, Minneapolis, Sept. 15, 1989
4 “Paul M. Ellwood, Jr., MD, In First Person: An Oral History,” American Hospital Association, Center for Hospital and Healthcare Administration History and Health Research & Educational Trust, 2011