We’re on the Road to Somewhere

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Welcome to 90 Days to Change, the website developed in 2014 by a (now former) Kaiser Permanente psychotherapist to promote improvements in mental health services at California’s largest HMO. The First 90 Days (Reader’s Edition) provides an account of my last three months at Kaiser, as I promoted positive change from within. After being relieved of duty prematurely, I spent another three months reaching out to consumer protection agencies and politicians. You can read about this search for allies in The Second 90 Days (Reader’s Edition).

With the February 24, 2015 release of the Department of Managed Health Care’s stunning follow-up report,  I’m encouraged to jump back into the fray, to write about the next phase in the transformation, and to advocate for as rapid a change as possible.

Now that a California State agency has corroborated the testimony of Kaiser’s 2600 mental health practitioners, the pressure is really on the Feds to address the widespread and appalling treatment of people with mental illness, Americans under the legal protection of the Mental Health Parity and Addiction Equity Act (2008) and the Mental Health Parity Act (1996). The randomized audit of services, detailed in the State agency’s report, creates a precedent for a similar investigation to be led by the Centers for Medicare and Medicaid Services, concerning the subset of Kaiser mental health patients being treated by the Kaiser Advantage Medicare program. That will be my focus for the next ninety days.

So much has been accomplished already — by the psychotherapists at Kaiser, their patients, and their patients’ families and friends. As a result of years of perseverance, the State has started to do its part. It’s time for the Feds to do theirs.

Run DMHC!

Last week, on February 24, I got two emailed treats.

Jon Brooks from KQED, sent me a link to the Department of Managed Health Care’s just-released “Routine Survey Follow-up Report,” (a follow-up to the DMHC’s March 2013 report). He was curious about my comments which you can read in his article. Later that same day I got an email from Katie Gross, a staffer in US Senator Dianne Feinstein’s San Francisco office. Katie wanted to set up an immediate phone conversation to discuss my experience with Kaiser mental health. I spoke with her the next day, starting a conversation that I hope will end in a federal investigation into the Kaiser Advantage program. More on that in a bit.

But first, I offer a huge “thank you” to all to the folks at the DMHC who participated in the new report. By investigating follow-up services, (defined as any visit after an initial assessment), you’ve opened up a very large and slimy can of worms. Some may say that, considering the enormous pressure from consumers and therapists, you had no choice. But we all have our choices, including quitting our jobs if the going gets too rough. To those of you who stayed at your posts, thanks for going boldly. The report is five giant steps in the right direction.

The primary innovation in the DMHC’s follow-up report is a randomized medical record review. (A description of this review starts on page 18 of the report.) The DMHC hired a team of mental health professionals to review a random sampling of 300 notes charted between September 2012 and September 2013. This review yielded an estimate of how many mental health patients are underserved by the current system: 22% in Northern California and 9% in Southern California (from the report’s chart on page 19). I believe this is a serious underestimate of the problem, though I’m grateful for these numbers. The DMHC has finally started to assess and publicize the breadth of Kaiser’s negligence.

The chart review also produced clear evidence of the intransigence of Kaiser, the corporation, in the face of overwhelming evidence of the need to change. Witness this quotation from a Kaiser psychiatrist who emailed a patient: “’No one ever sees a therapist once a week in the Kaiser Health Plan. Not a covered benefit for the past 20 something years and will not be a benefit in the future.’” (From page 31.) This quotation is from a physician owner of The Permanente Medical Group, stating that no Kaiser member, not even someone with a parity mental health diagnosis, not even someone at grave risk for deterioration and suicide, no one gets weekly individual care from us. Furthermore, this psychiatrist taunts, this will never, ever change. (So quit asking.)

Sheesh!

It didn’t take a very large sampling of chart notes (300 charts reviewed) to reveal the corporate culture’s defiant stance toward parity laws. Nor did it take a large sample to reveal the breadth of the service gap resulting from physicians’ we’re-above-the-law position. Consider: “Case #B23: A sexual assault victim…diagnosed with post-traumatic stress disorder (PTSD) and major depression…. an appointment with a Plan therapist was scheduled five months after she was first seen.” (From page 31.) Or: “Case#R21: A child was brought in by her father due to the child’s aggressive behaviors, sexualized behaviors and significant behavioral problems in both the home and school environment… the child was not seen for therapy until seven weeks [after the initial assessment].” (On page 24.)

SO! The DMHC is starting to operationalize “timely care” in a manner that holds Kaiser more accountable. They’re also getting more precise about the health codes they’re citing to justify their increasing level of scrutiny. I wonder, along with you, what kind of fines will follow this report. (A separate arm of State government is responsible for levying the fines.) I wonder, too, if the fines will be suspended for a year or so, giving Kaiser the opportunity to restructure meaningfully. That’s what I would hope. A billion dollar fine, suspended, would possibly do the trick. This is a perfectly reasonable figure, since it will cost hundreds of millions of dollars in therapist salaries to approach the mandate of parity law. The fine must be greater than the cost of change to be effective at promoting change.

Now that the State has stepped up its game, it’s time for the Feds to follow suit, focusing on Medicare and Medicaid’s slice of the Kaiser membership pie.

For years, a significant portion of Kaiser members, including those with mental illness, have been funded by Medicare, under the Kaiser Advantage program. Since January 2014, the Affordable Care Act added another portion of publically-subsidized members to Kaiser, these funded by Medicaid (MediCal in California). Throughout, Kaiser has been given a complete pass on how they deliver mental health services under these entitlement programs. It’s been four years since Kaiser therapists published their white paper about the serious deficiencies in access to mental health care; and there has yet to be a comprehensive audit of Medicare’s mental health services.

Here’s what I am going to urge Senator Feinstein do, on behalf of federal taxpayers and Medicare and Medicaid recipients being denied mental health care on a daily basis. (1) Request that the Centers for Medicare and Medicaid Services (CMS) conduct an audit of mental health services delivered to Medicare and Medicaid recipients, and publish their results. And (2), sponsor an investigation into how Kaiser has, to this point, gotten away with defying federal parity laws.

I can only hope the Senator seizes this opportunity.

Family Member of Northern California Kaiser Member Speaks Out

I am grandmother of a young man who lost two precious years of his life seeking mental illness treatment at Kaiser Sacramento, two years when he really wanted a reliable psychiatrist and a therapist he could trust, when he had the maximum potential to manage his illness, and become independent. In those two years, we learned that Kaiser denies clients the option to have a schedule of appointments with a therapist/psychologist and maintain any routine appointment times. There is no such thing as an agreement to meet every other Thursday at 3PM–appointments are always fluid. The therapist could not make a commitment to any future appointment until some unknown time when he could call for another appt. There is no schedule that clients can plan upon. My grandson could never make a follow-up appointment with a doctor before leaving the clinic; he always had to “call in a couple of weeks.” There is no treatment plan for clients, the psychiatrist had no contact with a revolving number of therapists/psychologists, and they made no attempt to contact the psychiatrist.

Therapists cancelled appointments on the day of the appointment at least three times. Clerks cancelled appointments because the therapist needed another day of vacation.After seeing the same psychiatrist a couple of times in 2012, he could not get another appointment. The scheduler kept saying the doctor was not making any appointments. After a couple of months we finally called “Member Services’ to complain and found out that the doctor had already left Kaiser shortly after the last visit.

Psychiatrist appointments were cancelled month after month. In 2013, a July appointment was rescheduled for August, that was rescheduled for September, and that was rescheduled for October when the doctor was finally in, and my grandson was seen for the first time since the previous April. By that time, he wanted nothing to do with that system and had no expectations of seeing anyone who wasn’t a stranger at every visit. This is the quality of “treatment” offered to a young man who knew he needed expert medical attention, and wanted advice he could rely upon.

This was an absolute violation of trust that undermines the hopes and heart and waning energy of someone already fighting the odds.

The worst has already happened in our family, and we have lost two brave men who died by suicide. Kaiser practices amount to malpractice.

The $4 Million state fine was a small price for them to pay for running a racket that fleeces people of hope, along with their premiums.

Poor Kaiser!

Please forgive a brief interruption in my presentation of client and therapist stories…

As Kaiser Permanente and the National Union of Healthcare Workers square off for next week’s strike, I’ve been noticing subtle but significant shifts in Kaiser’s media strategy. For one thing, in articles from newspapers across California, one spokesperson seems to be doing all the talking: John Nelson, whose title is given as “Vice President of Government Relations.” This may have been his full title all along, but I don’t recall anything other than “a vice president” or “a senior vice president” attached to his press statements in the past. “Government Relations” suggests that he interfaces with the California Department of Managed Health Care (DMHC) and/or the federal Centers for Medicare and Medicaid. This further suggests that Kaiser is now defending its record of inadequate mental health services first and foremost to the government. The statements Mr. Nelson is making are actually a very poor defense of Kaiser’s track record. They can be challenged by the press with a minimal amount of research. Challenge they will. And apparently the government will be listening to how the Vice President of Government Relations rebuts.

This is significant because the DMHC has yet to release its follow-up report about Kaiser mental health services, the one in which they are expected to speak to the broader issue of continuity of care (treatment after the first visit). The report was originally promised in November 2014. When I wrote Rodger Butler, spokesperson for the DMHC, on December 2 he said he thought the target had always been November or December. When I wrote again on December 26 he replied “it will likely be in January, but things could change.” Perhaps they’re waiting to see how much impact the strike will have before enforcing a new set of conditions. The DMHC is, after all, under the leadershiip of the governor. And the governor must ration his policital clout.

In yesterday’s Santa Rosa Press Democrat, Mr. Nelson was quoted as saying Kaiser “’is not where we want to be’” in its provision of mental health services. According to an LA Daily report, he told reporters that they are “not where they want to be” because they are “’battling a nationwide shortage in behavioral health specialists.’” And in multiple papers he has been promoting the rest of Kaiser’s new story. Which is that Kaiser is already hiring way ahead of the growth of their membership, (for example, in 2014 “‘membership rose by 8%'” and Kaiser “‘hired 25% more staff than they had the year before'”). And that (and this is their old story) the strike is only about benefits.

I was particularly excited to hear a spokesperson acknowledge that services were “not where we want them to be.” This past September, when Kaiser pulled out of the court case challenging the DMHC’s $4 million fine, they posted on their new website (share.kaiserpermanente.org) that even though “we were not in violation with the timely access regulation” they were dropping the case to “forego the expense and distraction of litigation.” This was hardly an admission of guilt or even a taking of responsibility. And, yes, it would have been very expensive and distracting to develop a legal argument for the court along with a public relations campaign for future Kaiser members that could dispute the experience of hundreds of thousands of Kaiser customers and their therapists.

Instead, Kaiser continues to say that everyone in managed care is struggling the same way on the same boat, but that Kaiser is just the big fish being punished. This “poor Kaiser” part is not particularly new. But suggesting that there’s a national shortage of therapists, when there’s an excess of therapists in most major cities where Kaiser operates in California, is new, spurious, and a flat out bad career move. I’ll leave it to the union and the press to come up with the statistics to dispute Kaiser’s absurd claim of scarcity. It shouldn’t take long to Google the numbers of therapists in, e.g,, San Francisco, Oakland, Los Angeles, and San Diego, to name a few of the cities where clients wait at least four weeks between individual therapy appointments.

The applicant pool is shallow not because of a scarcity of therapists. I’ll remind my dear readers of the premise of this blog. I left Kaiser because I was unable to find a way to practice ethically within their system. I would have loved to stay and continue the good work I was doing, fairly compensated, with clients who needed my help. I left because Kaiser does not prioritize individual therapy, the heart of mental health treatment. And of the therapists I’ve met in the private practice world since I left, every last one has heard that Kaiser does not allow adequate individual time. Like me, they would love to work for an agency like Kaiser, one that provides excellent compensation, job security, and a steady flow of appropriate clients. But also like me, they will not trade quality client care for good money.

Lastly, I encourage the press to investigate the facts behind Nelson’s statistics about membership growth. Kaiser has increased the absolute number of therapists, true. Increased hiring started when they were fined by the DMHC and told to meet the letter of the law for initial access or get more fines. They’ve increased staff and are still unable to get clients to treatment in a timely fashion because they’re busy catching up with a decade of neglect. My conservative estimate is that they will have to double their staff to provide appropriate service. They need to restructure and reorganize, too. The Affordable Care Act changed Kaiser’s membership in ways that need more specialized staff, particularly case managers to work with the low income, severely mentally ill people now in the mix since MediCal expanded and since Kaiser took over their treatment from county care.

“Not where we want to be…” is a start. But where do you want to be, John Nelson? Of the deficits pointed out by therapists over the last four years, which are you planning to address? Timely access to a therapist for evaluation? Continuity of care with a primary therapist who can see clients as clinically appropriate?  Case management services for the seriously mentally ill clients who need them?  Crisis services and follow-up care?

You have over 2600 therapists willing to join you in the task of rehabilitating the system. If you want to get somewhere, you’re not alone. They do, too.

Private Practice Therapist Speaks Out on Behalf of her Northern California Kaiser Client

“Several months ago I met with a new client in my private practice who told me she had Medicare, which was contracted through Kaiser. This client had been speaking with a Kaiser psychiatrist for years, but only by phone. During our initial assessment, I discovered that my client had been unable to leave her home for years during daytime hours due to severe agoraphobia caused by lifelong sexual trauma. She was also actively suicidal, had been hospitalized twice during the past year, and was struggling to remain sober. She assumed her Medicare would cover her therapy with me, and was finally willing to try individual therapy because my office was two blocks from her home, a distance that was extremely anxiety-provoking, but worth it to her to receive treatment.

“Of course I soon found out that Kaiser would only cover her therapy if it was approved as medically necessary. Her psychiatrist at the Richmond facility said this could only be approved by her supervisor.  It was not approved.  I pressed with more details of the client’s situation and was finally told that perhaps a social worker could be sent.  This never happened.  I consulted with a managed care regulatory board that worked with Medicare patients and was told to submit a complaint to them, and then a formal complaint to Kaiser. They also told me that most likely nothing would happen.  I have not yet submitted a formal complaint to Kaiser.

“I have continued to see this client pro bono because of her suicidality and because I plan to continue to fight with Kaiser to approve my services.   And, of course, because I don’t want to be part of a system that refuses service to people in need.”

Southern California Kaiser Client Tells Her Story

The day after I opened up this forum, I immediately got a response. Makes me think we’re on to something…

“In 2010 I was laid off from my job. I had been working as a San Diego area teacher for over 30 years. My husband and I sold our house and downsized to a smaller home. Just six months later the new car dealership my husband had worked at for the last 12 years closed its doors. We were 53 and 57 and both unemployed now. I was quickly spiraling downwards emotionally.

“I contacted Kaiser Permanente to obtain a Zoloft prescription, a drug I had used once before but no longer was taking. They had the Shadowridge mental health facility in Vista contact me, and they did a quick over the phone interview. I was set up with an appointment to see a psychiatrist in six weeks — a long wait. The day before my appointment they called me and said the doctor had the flu, but if I came in they would find someone else to see me. I declined, as I was nervous about seeing “someone” without knowing anything about who that person was. I asked if a doctor could just prescribe me the Zoloft over the phone, and the nurse refused. I then asked for another appointment with the psychiatrist I had originally been scheduled with. The nurse set me up with a new appointment – in ANOTHER six weeks.

“Even though my husband and I were paying $1,200 in insurance premiums each month to Kaiser, I eventually became so depressed that I made an appointment with an out-of-network psychiatrist who had once prescribed the Zoloft to me years earlier.  By this time I was feeling suicidal and was also having panic attacks. The out-of-network doctor diagnosed me with severe panic disorder and depression. He recommended marriage counseling, but we couldn’t afford it and our Kaiser insurance wouldn’t cover it. We ended up going to our church, which had a licensed psychologist and MFT doing marriage counseling at a reduced rate of $50 per session. We attended 10 times. By now I was paying out-of-pocket for the every-2-months psychiatrist visit, the Zoloft, the marriage counseling AND paying $600 each month to Kaiser for my insurance. And my husband and I were both still unemployed.

“Eventually I heard about the DMHC fine and the cease and desist letter to Kaiser regarding the violations in their mental health care. I contacted the company by e-mail and asked what they knew about it. They claimed that they were “formulating a response” and would be sending letters out very soon. ( I still have a copy of the e-mail Kaiser sent me  in response to my inquiries) They never did send a letter as they promised. In the meantime I was discovering details on my own about the DMHC violations.

“I decided to make a formal complaint to Kaiser asking for compensation for the 5 psychiatric visits, the cost of the Zoloft, and the 10 visits to the marriage counselor. Even though I sent a detailed letter, and letters from these out-of-network mental health professionals documenting my expenses, Kaiser refused to reimburse me. Kaiser claimed that I had no claim to reimbursement since I went out of network.

“If I had NOT gone out-of-network to get help when I finally did, I believe I might have committed suicide. I was having suicidal ideation nearly every day by then. After Kaiser denied my claim, I sent a letter to the DMHC detailing all of my circumstances and asked them to investigate Kaiser and also to let me know if there would be any class action lawsuits against Kaiser in the future. In truth, I don’t care about compensation — it totaled $1,000. (I have since received a large inheritance and I do not need the money.) I am more interested in being an advocate for other California health care consumers.”