The Story of Dr. Sidney R. Garfield

By JON STEWART

“It’s about time,” declares Jay Crosson, MD, a recently retired physician executive at Kaiser Permanente, in his foreword to The Story of Sidney R. Garfield – The Visionary Who Turned Sick Care into Health Care (Permanente Press, 2009). “For too long,” writes Crosson, “Sidney Garfield has stood in the giant shadow cast by his more celebrated partner and friend, Henry J. Kaiser… (whose) name and fame live on, mainly in association with the only nonprofit organization ever incorporated by the builder of more than 100 for-profit companies – Kaiser Permanente. But the physician whose extraordinary vision and daring innovations in health care delivery gave birth to that same organization remains largely unrecognized beyond the select circle of medical historians and the heritage-minded physicians and staff of Kaiser Permanente.”

Sidney R. Garfield (1905-1984) is indeed one of the great under-appreciated geniuses of 20th century American medicine.

Starting out from the humble beginnings of a 12-bed hospital in the middle of southern California’s Mojave Desert, where he tended to injured industrial workers on the California aqueduct through the early years of the Great Depression, he not only went on to create the nation’s largest private, nonprofit, vertically integrated health care organization (Kaiser Permanente); he virtually reinvented the economics and organizational structure of health care delivery by envisioning and demonstrating the manifold advantages of the prepaid, group practice model  – a model that many today view as a necessary element of effective health care reform.

Garfield was certainly not the first or the only physician to embrace the notion of prepayment – what we call capitation today. Nor was he the first to understand that physicians working shoulder to shoulder in multi-specialty groups could, through collaboration and continuity of care, outperform their solo practice colleagues in almost every measure of quality and efficiency. The Mayo brothers had prior claim to that distinction.

What Garfield did, uniquely, was marry prepayment to group practice, thus providing aligned financial incentives across every physician and specialty in his medical group, as well as a culture of group accountability for the care of every member of the affiliated health plan. He called it “the new economics of medicine,” and at its heart was a fundamentally new paradigm of care that emphasized prevention before treatment and  health before sickness.  “How much wiser to transfer the economy of medicine to payment for keeping the patient well,” he said. “Such becomes the case with prepaid group practice medicine operating in efficient and adequate facilities. Under these conditions, the fewer the sick, the more remuneration; the less serious the illness, the better off the patient and the doctors.”

Such ideas were heresy to the reigning fee-for-service, solo practice ideologues of the mainstream medical establishment of the 1940s and ‘50s, of course. Throughout the period, Garfield and his group physicians were routinely castigated by leaders of the AMA and county medical associations as socialistic and unethical. The local medical associations in Garfield’s expanding service areas – the San Francisco Bay Area, Los Angeles, and Portland, Ore. -- blocked group practice physicians (mainly Garfield’s) from association membership, effectively shutting them out of local hospitals, denying them patient referrals or specialty society accreditation. Twice in the 1940s, formal medical association charges were brought against Garfield personally, at one time temporarily succeeding in suspending his license to practice medicine.

But Garfield’s battles with the medical establishment, heroic as they may have been, are really only a minor theme in his story compared to the remarkable innovations he championed in the delivery of medical care – from hospital design to mass, routine health screenings to the implementation of computerized health records in the early 1960s, and ending with a massive research project dubbed “Total Health Care” that lay the groundwork for the reorganization of primary care on the basis of multidisciplinary teams of physicians, nurses, mental health practitioners, health educators, nutritionists and others.

The authors of the current biography, Tom Debley and collaborator Jon Stewart (myself), both current Kaiser Permanente employees and history buffs, hope that this short introduction to Sidney Garfield will help restore Garfield to the prominence he deserves. Even more, we hope it will inspire independent scholars to take a fresh look at Garfield’s remarkable life and accomplishments and give him the full-scale biography he so obviously merits.

John Stewart is an old colleague of mine from my IFTF days when we worked together on the ten year forecast of Health and Health Care in the late 1990s (Don't ask if our forecast was right!). He's  since ended up at Kaiser where he's been involved in some historical archaeology digging up the story of the early Permanente Group, started by Henry Kaiser's brother-in-law Sidney Garfield. He sent me a book that they've just published about Garfield, and rather than actually do the hard work of reviewing it myself, I asked John to write a summary. Be warned that, just like the organization he founded, Garfield has his detractors who don't get mentioned here (but they may show up in the comments). But I thought that you'd find this an interesting historical perspective--especially to those of you who don't know how those weirdo group practices doctors were shunned by their peers back in the good old days. Which is one reason there still aren't that many of them around! Matthew Holt