A Game So Nice I’ll Play it Twice

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New to this website? Welcome! If you’re looking for the story about my last three months at Kaiser, fighting the system from the inside out, you can find all the posts in order at the tab “The First 90 Days (Reader’s Edition).” Happy reading!

I’ve launched a second ninety day campaign to reform the delivery of mental health services at Kaiser. After a rejuvenating summer, I jumped off the fence to organize a new wave of challenges to the current system of care. While the first “90 Days” might be seen as a primer for fighting an institution from the inside out, the next segment (from October 2014 through New Year’s Day), will, if I’m lucky, demonstrate how one person can make a difference from the outside.

Now that I’m no longer an employee of The Permanente Medical Group (TPMG), and am no longer a card carrying member of the National Union of Healthcare Workers (NUHW), my perspective on the global deficits in Kaiser’s mental health program has changed. Now I’m a concerned member of the community — we all suffer when the number one provider of mental health services in California delivers less than adequate care. I speak also as a private therapist who sees the fallout of poor treatment in my Kaiser member clients, those who paid their premiums through their employer, privately, or through the Medicare or Medicaid system. I speak as a payer of state and federal taxes, subsidizing these substandard, federally- and state-funded mental health programs.

On September 9, 2014, moments before they were slated to argue their case in front of an administrative law judge in Oakland, Kaiser dropped its appeal of the Department of Managed Health Care’s $4 million fine. (The fine, if you recall, was levied for delaying access to initial mental health appointments and for discouraging members from seeking services, e.g. by telling them that Kaiser doesn’t offer individual psychotherapy.) Just as remarkably, Kaiser has begun to develop protocols to subcontract the overflow of psychiatry department intakes to a behavioral managed health care group, ValueOptions.

These are incredible developments! In the first case, Kaiser lawyers must have withdrawn because they knew they couldn’t prove Kaiser mental health administrators had responded to the DMHC’s allegations sufficiently or quickly enough. And, by subcontracting mental health services to ValueOptions, Kaiser is admitting that they are unable to do the job without hiring more help. That, in fact, they are understaffed. Which is what therapists have been shouting for three years now.

This is no time to take the pressure off! As a corporation, Kaiser will spend as little money as possible appeasing state regulators. They will continue to need their feet held to the fire if they are going to implement meaningful change.

So, whether you’re inside Kaiser, fighting to get your clients the basic help they need,  or out, trying to improve the mental health of our entire community, let’s keep this mighty ball a-rollin’!

(90 days (or so) to go.)

Dear Mr. President

I had to break this letter into three parts to get it through the whitehouse.gov website which has a 2500 character limit for email correspondences. (The things we do for love.)

Dear President Obama,

I am a mental health professional living and working in Northern California. I very much appreciate all your efforts to date improving access to quality health care.  As some health services are becoming available to a wider swath of Americans, I am concerned that availability of behavioral health services is lagging far behind. My most recent professional experience, eight years as a staff therapist working for the largest HMO in the US, Kaiser Permanente, taught me that despite federal and state parity laws, even the most basic mental health treatments are not being provided in the HMO setting. Since more and more Americans receive their care from HMOs, including the millions of people supported by Medicare Advantage and Medicaid programs, I have spent a good deal of energy attempting to raise awareness of these deficits. I am writing to you because consumers and providers need the help of political leaders to advocate for the profound changes required. Without refinements to our health codes and enforcement by our justice departments, HMOs will continue on their current course of extreme negligence.

Since February 2014 I have been documenting Kaiser’s mental health care deficits on my website 90daystochange.com. To summarize, over the course of my time in the Psychiatry Department at Kaiser Permanente’s Santa Rosa Medical Center, the waits between individual appointments with a primary therapist averaged 4-8 weeks, regardless of the severity of the patient’s symptoms. As you may know, California’s HMO regulatory agency fined Kaiser $4 million last year for delaying initial access to therapists and psychiatrists. In an attempt to address the regulators’ specific concerns, Kaiser made some superficial changes. These changes have not impacted the basic structure of how Kaiser provides behavioral health services. The four- to eight-week waits between individual appointments continue.

Kaiser members have much more reliable access to their primary care physicians (PCPs). PCPs authorize follow-up care, including with themselves. They have the authority to regulate frequency of visits with their patients. PCPs also have panel limits: when their availability becomes unacceptable, according to well-defined standards, their panels are closed. If there aren’t enough PCPs to meet demand, Kaiser hires more. Psychiatry Departments at Kaiser lack analogous structures. As a result, behavioral health patients are denied comparable access to their therapists. With next available appointment slots one to two months away, therapists cannot offer weekly or bi-weekly therapy, even in acute cases. For therapists, there is no limit to panel size and no patient to therapist ratio to inform Kaiser when to hire more staff.

Effective treatment in the mental health world, just as in the physical health world, requires a trusting relationship between provider and patient. Mental health treatment is, in large part, provided in one-on-one private conversations. PCPs are often able to address health conditions in a 15 or 30 minute visit, but therapists cannot — especially not during the first few critical sessions when trust is required for the patient to disclose the wider clinical picture. Trust is also required before patients will follow therapist recommendations to attend skills groups that teach strategies for managing strong emotions. Due to a lack of one-on-one support from individual therapists, the drop-out rate from Kaiser skills groups is 75%.

Quality assurance mechanisms to address treatments for “physical” conditions at Kaiser are stunningly absent for mental health conditions. If a regulator wants to know how Kaiser is doing at preventing heart attacks, diabetes, or hospital-based infections, as examples, the data is readily available. But how about for suicides? Suicide is the preventable consequence of untreated or unsuccessfully-treated depression. But Kaiser neither tracks suicides across its vast database, nor does it hold suicide prevention as a goal. In fact, Kaiser does its best to suppress information about suicide in order to avoid accountability. Some Kaiser therapists and physicians have lost their jobs attempting to address concerns about patient safety due to lack of therapist resources. Over the last two years in Santa Rosa, Kaiser went so far as to disband its functional, multi-disciplinary quality assurance committee, whose job (delineated in state and federal health codes) was to investigate suicides in order to prevent future treatment failures.

I am sending this letter to a variety of government officials, including to you, Mr. President, hoping it finds its way to those parties already working on improving mental health care within HMOs. I know your list is long, but please add mental health care to your priorities for the remaining time you have in office.

I am available for any assistance you may need: additional information, suggestions, encouragement. You can reach me by email at andyweisskoff@gmail.com or telephone at (707) 799-4125.

Thanks, again, for your attention to the health care of all Americans.

With Plenty of Admiration,

Andy Weisskoff, Licensed Clinical Social Worker

(22 days to go.)

Yanking Up the Chain

I think I’m coming to the end of what I can do from outside the Kaiser system to impact the mental health services they provide. Which, I have to say, is a huge relief. The time has at last come to contact every politician I can, to formulate the best argument I can to encourage their involvement in these issues. And then to ease myself away, away, away.

Earlier this week I ran across a bill sponsored by U.S. Senator Tim Murphy (R) from Pennsylvania which addresses gaps in mental health services nation-wide. The bill seems focused on developing inpatient resources for people with serious mental illness and on removing barriers that prevent families from participating (usefully) in care. I tried to use Tim’s government website to send him a message encouraging him to broaden his campaign to include basic mental health care provided by HMOs. But I couldn’t change the pre-populated field for “state” from PA to CA. I suppose the problem was that I’m not exactly from Pennsylvania, so Tim’s not exactly my guy. I should have remembered this from my Schoolhouse Rock education. 

Instead of to Tim, I sent the following email today to my real guys — U.S. Senators Boxer and Feinstein. I’ve been voting for them for a long, long time.  But until this point I’ve never even asked them for the time of day. That’s about to change.

Dear Senator (insert Boxer or Feinstein here) and Staff:

Thanks so much for your efforts to date directed toward improving mental health services in California. I’ve been providing mental health treatment to residents of Northern California for the past twenty years and hope to continue for another twenty. I’m writing today to enlist your help in drafting new laws to promote mental health parity through HMOs, where the vast majority of mental health care takes place.

For the past eight years or so, I’ve been a staff psychotherapist at Kaiser Permanente’s Santa Rosa Medical Center. As you probably know, Kaiser is the number one provider of health and mental health services in California. I worked in the outpatient mental health clinic from September 2006 through this past May 2014. I resigned my position because, due to severe understaffing, I was unable to offer my patients the individual attention they needed. Over the years, I believe at least one of my patients killed himself because he didn’t receive timely care from me. Countless others declined in their health and missed opportunities to improve their quality of life because I couldn’t offer them the one-on-one time they needed.

For the last three months of my time at Kaiser, I blogged my efforts to change the system at 90daystochange.com. I was relieved of duty three weeks ahead of the agreed-upon resignation date, the day after I began documenting that my patients were at risk for decompensation and suicide due to understaffing. Please read my blog for a thorough description of Kaiser’s misbehavior toward its mental health patients. This letter to you is today’s entry!

Primary physical treatment at Kaiser is structured around the ongoing relationship between a primary care doctor and patient. This relationship is understood by patient and provider alike to be central to effective ongoing care. Though parity laws require otherwise, a mental health patient who comes to a Kaiser psychiatry clinic seeking a similar relationship from a primary therapist rarely gets the kind of relationship they need in order to recover from their condition. Over the course of my almost eight years at Kaiser, waits between one-on-one appointments were, on average, 4-8 weeks, regardless of severity of symptoms. That average held true across therapists and across Kaiser medical centers throughout California. As a result of the scarcity of individual appointments, the most common treatment course for a new mental health patient at Kaiser was and is: meet with a therapist once for an hour; schedule a follow-up with this therapist in one to two months; get a referral to a psycho-educational group (regardless of readiness or willingness to attend); and (not surprisingly) lose hope and drop out of treatment.

Recently I’ve been following up on my advocacy of Kaiser members with the Centers for Medicare and Medicaid Services. I’ve made a report of Medicare fraud/abuse (case #31144 being investigated by Health Integrity LLC) and a quality of care complaint (currently with the BFCC-QIO Livanta). Though well-substantiated, I believe my reports will be ignored due to the low priority given mental health treatments versus medical treatments. You can read my reports on the 90daystochange website. If there’s anything you can do to promote the investigation of Medicare abuse by Kaiser psychiatry, I would appreciate it.

The greatest barrier to enforcing quality standards for mental health treatment is imprecise language in state and federal health codes. The DMHC was only able to fine Kaiser $4 million because Kaiser was failing to meet clear standards for initial access to care. Unfortunately the codes do not describe standards for treatment once a client is in the door, so the DMHC can only go so far. I think the best fix for this flaw is to change the codes to specify: (1) that each mental health patient is assigned a primary therapist, (2) that this therapist has the authority to initiate the optimum treatment plan, and (3) the therapist has the capacity (room in their schedule) to see their patients weekly or twice weekly when necessary. Language in MOUs between Kaiser and Medicare Advantage are, no doubt, as vague as state laws concerning frequency of individual visits, and so need similar attention.

Kaiser is swiftly becoming the standard of health and mental health care for the United States, making it extremely important that they provide and model appropriate mental health treatment. The $4 million fine from the DMHC has nudged Kaiser in the direction of improving services, but it is ultimately insufficient to prompt long term significant change. It is in the nature of managed care to provide the minimum required by law. And since that’s what Kaiser is doing, the laws must change if we are to expect improved care.

If there’s any additional information I can provide, please get in touch. And thanks too for all your years of service!

Sincerely,

Andy Weisskoff, Licensed Clinical Social Worker
LCS -20126

(29 days to go.)

A Quality Complaint

It hasn’t been easy, following up on Belinda’s recommendation to pursue a quality of care complaint regarding mental health services at Kaiser (see my post “Does Kaiser Advantage Have Integrity?“) I’ll spare you the tedious path I followed, but let you know the exciting conclusion: all roads lead to Livanta, the Medicare Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Area 5, which includes California. According to their website, Livanta “manage[s] all beneficiary complaints and quality of care case reviews.” A recording on their Helpline (877) 588-1123 indicated  I could email a “complaint specialist” at kroundtree@livanta.com.

I just emailed the following complaint to k…

I understand that Livanta is the BFCC-QIO responsible for Medicare quality of care case reviews in California. I am using every avenue possible to improve basic mental health care services at Kaiser Permanente — perhaps the largest provider of mental health services in California – and believe that a quality of care complaint is appropriate and has the potential to actualize these improvements.

I am a Licensed Clinical Social Worker, licensed to diagnose and treat mental illness in the state of California since December 2000. I worked as a staff psychotherapist at Kaiser Permanente’s Santa Rosa Medical Center, in their Psychiatry Department from September 2006 to May 2014. Throughout my time at Kaiser I witnessed and participated in a system-wide practice of under-treating mental health conditions, including those conditions that lead to suicide. This practice involves not hiring enough licensed psychotherapists to provide weekly individual sessions for people at risk for deterioration of their mental status without them. It also involves an over-reliance on educational groups in place of individual care.

To this point Kaiser has been able to maintain the appearance of quality care in its absence by minimizing meaningful quality care reviews and avoiding tracking suicides across the system. Despite national recognition of depression as a serious and prevalent medical condition, throughout my time at Kaiser suicide prevention was never stated as a programmatic goal, neither for the Psychiatry Department, nor for the Santa Rosa Medical Center. A quality goal of reducing suicide would necessitate developing an action plan to achieve that goal. It would also require a system to measure accurately suicides over time. But as far as I can determine, suicides are not now and have never been tracked anywhere in the Kaiser system.

The Psychiatry Department in Santa Rosa once had a quality assurance program, albeit with significant flaws, designed specifically to address system errors leading to patient suicides. Prior to 2013, we had an organized committee of therapists and psychiatrists, representing social worker, psychologist and MD disciplines, from the three teams that work in the department collaboratively – the adult team, chemical dependency team, and child and family team. The committee periodically received cases of suicide sent to them by the Medical Center’s “Chief of Quality.” The medical records were reviewed by committee members and other department staff of various disciplines; clinicians who had participated in the deceased patient’s care were often interviewed to further clarify the case.

The deepest flaws in this committee’s review process were: (1) inconsistent identification of new cases for review, (2) the committee’s lack of authority to implement changes, i.e. to turn their conclusions about system deficits into program improvements, and (3) the absence of communication between quality assurance committees across the state. I became aware of the first problem when two patients I had worked with killed themselves within a year. I found out about these suicides incidentally — in one case from a family member and in the other through the media. Neither case was reviewed by our quality assurance committee.

These flaws were exacerbated by the deteriorating situation between physicians and therapists over the course of a three-year therapist contract dispute, starting in 2011. At that time, Kaiser management began withholding from therapists any information that might be used in our dual campaign for an advantageous contract and quality care for our patients. In this context, in 2013, the quality chief in Santa Rosa stopped sending cases to the committee. Contrary to state and federal law, the committee’s work  was replaced by a single physician to review cases.  The committee members protested this change. Therapists within the department created a quality of care complaint, saying that the switch from committee review to physician review was in retaliation for whistle-blowing about poor (illegal) access to treatment. The retaliation case was reviewed by an investigator hired by Kaiser and dismissed as groundless. The single physician review of cases remains in place in Santa Rosa.

To review: Kaiser has yet to identify suicide prevention as a quality goal. As a result, they do not have effective systems in place to track suicides within medical centers and across the entire network. A process that they had set up to create at least the appearance of targeting suicide was dismantled in 2013 in the context of an ongoing labor dispute. Therapists at Kaiser are united in their belief that understaffing is contributing to poor outcomes including suicide. Currently there is no quality review system in place to confirm or disprove this assertion. There is, in fact, no meaningful quality of care system to review the management of mental illness at Kaiser at all, even as regards the most dire consequence of under-treated mental illness.

You can read more about poor quality mental health care at Kaiser on my blog site 90daystochange.com. I hope you are willing to help me get this complaint to the appropriate reviewer in a timely fashion.

(32 days to go.)

Medicare Refresh

I decided it might make sense to hone my argument about why I believe the inadequate mental health services provided by Kaiser constitute Medicare fraud, and to email and snailmail my honed argument to Belinda Cross at Health Integrity. So here’s what I wrote and sent today. I incorporated what I learned from my conversation with Belinda on 11/13/14 regarding an annual process reconciling delivery of services with monies reimbursed. Even though there are big holes in my understanding of how the whole process works, it seems that those with a clearer understanding of the system will be able to fill in the blanks.

I am a former staff therapist who worked at Kaiser Santa Rosa’s Medical Center in the Psychiatry Department, starting in September 2006 and ending almost eight years later when I was escorted from my office in retaliation for whistle-blowing in May 2014. As a steward for the union of Kaiser’s psychotherapists, the National Union of Healthcare Workers, I was privy to information about policies, procedures, and their effects at Kaiser medical centers beyond Santa Rosa — throughout Northern and Southern California. And I believe the same policies that operate in California are in place at Kaiser medical centers throughout the United States which leads me to believe that the fraud I am reporting here is operating on an enormous scale.

My belief that The Kaiser Medical Group (TPMG) has defrauded the Medicare Advantage program is based on a partial understanding of how Medicare reimburses Kaiser. I will describe my experience with clinic policies and leave it up to you to assess if you believe, as I suspect, that there is a strong case for fraud. My understanding is that if there seems to be a strong case, then you forward your information on to the Office of Inspector General for further investigation.

Starting several years ago, therapists and psychiatrists in the Psychiatry Department in Santa Rosa were instructed to fill out a form known as “Medicare refresh” whenever the form appeared in our mail boxes. The form listed one or more diagnoses. Therapists had been instructed to check a box next to each diagnosis, verifying that the patient would be continuing to receive treatment for the diagnosis listed. Sometimes the forms contained “physical” diagnoses, like Hypertension. Therapists in Santa Rosa were instructed to comment on mental health diagnoses only. The most common diagnoses that we “refreshed” were Major Depression and Panic Disorder.  About a year before I left work for Kaiser, a more thorough training was given regarding the Medicare refresh process. In addition to filling out the paper forms, we were instructed to chart in each patient’s electronic medical record a plan to treat the conditions being refreshed.

My understanding is that these forms are part of a system that Kaiser uses to get reimbursed by Medicare Advantage for medical conditions that raise patients’ “risk scores.”  I further understand that there is a “reconciliation” process by which Medicare auditors review a sampling of cases in order to ensure that patients with higher risk scores are receiving diagnosis-specific treatments for the conditions that raised their risk scores. The reconciliation process implies that Medicare auditors compare treatment provided (services rendered) against a standard of care for each diagnosis.

If there is any standard of care expected for treating mental health conditions, I believe it is not being met by the behavioral health system in place at Kaiser in California. It appears fraudulent, therefore, that Kaiser accepts these payments for services never or only partially rendered.

Throughout my tenure at Kaiser, treatment of mental illness has been inadequate in at least two significant ways:  (1) markedly poor access to primary individual therapists and (2) an over-reliance on group programs. These inadequacies contradict the assumption (in the Medicare refresh process) that effective treatment plans for mental health patients are in place.

Markedly Poor Access to Primary Individual Therapists

Throughout my years at Kaiser in Santa Rosa, the waits between appointments with a primary individual therapist were, on average, 4 weeks, regardless of the seriousness of the patients’ symptoms. In the last year I was there, these waits got even worse in Santa Rosa, averaging 6 weeks. I was able, through my activities as a union steward, to confirm an average of 4-8 weeks between appointments with primary individual therapists across California and across conditions being treated. Due to the intervention of the California Department of Managed Health Care (DMHC), the amount of time a new patient currently waits for an initial appointment has in some medical centers improved. But according to my colleagues still at Kaiser, waits between follow-up appointments after that initial screen continue at their historical, unacceptable level.

Over-reliance on Group Programs

Kaiser has attempted to defend their short supply of individual therapy appointments by stating that their group programs provide better care than individual appointments. And this might be true, if it weren’t for the fact that most people do not attend the groups. Over the almost eight years I worked at Kaiser, the drop out rate for the groups addressing the two most often reimbursed categories of mental illness, Panic Disorder and Major Depression, had a drop out rate of 75%. That means that three out of four patients drop out of treatment between the initial referral to the group and the group’s final session. Without proper support from an individual therapist, the vast majority of patients do not complete the treatment plan that Medicare is reimbursing.

In summary, Kaiser is being reimbursed by Medicare to provide the additional resources necessary for treatment of certain mental health conditions. Therapists and psychiatrists are by rote signing off on the paperwork supporting this system. Therapists are unified in asserting that the supply of individual therapy hours is woefully inadequate to provide meaningful treatment and that group programs are only effective for the small percentage of patients that complete the programs. Under pressure from the DMHC, Kaiser is starting to increase its supply of individual therapy hours. It will be quite some time, however, before supply meets the ever-increasing demand.

Medicare Advantage should be refunded all the monies paid over the years to Kaiser for treatments promised through the risk score process but not provided. Future reimbursements for mental health conditions should be withheld until the supply of therapists is adequate to treat those conditions being reimbursed.

(38 days to go.)

Does Kaiser Advantage Have Integrity? Belinda’s on the Case

Today I sent the following email to Belinda Cross, the supervisor at the NBI MEDIC contract agency Health Integrity, (see my November 13 post, immediately below):

Hi Belinda,

Thanks for spending so much time with me on the phone last Thursday!

I hope I made it clear that I have a large personal investment in changing the Kaiser mental health care system for the better. I was a therapist in the psychiatry department of the Santa Rosa Medical Center for eight years ending in May 2014. I resigned my job because I was unable in good conscience to continue accepting payment for providing inadequate care. I am pursuing the claim of Medicare fraud because I believe that with the correct leverage from all available sources, Kaiser will change course and provide parity mental health services, as required by state and federal law.

On my way out of Kaiser this past spring, I blogged my efforts to change the system at 90daystochange.com. If you haven’t yet, please read this blog for clear documentation of my assertions. I have many colleagues, Kaiser therapists throughout California, willing to corroborate what I’ve written on my blog for your investigation of Kaiser Advantage fraud regarding Medicare recipients with mental illness.

I’m also telling you about my blog because I continue publicizing my efforts, including my contacts with you at Health Integrity. So far 90 Days to Change has had about thirty thousand visitors — primarily Kaiser therapists, managers, mental health clients and the media, including national and international reporters. This visibility contributed, I believe, to Kaiser’s eventual agreement to pay the California Department of Managed Health Care’s fine AND to Kaiser’s decision to start contracting with ValueOptions for therapist services to supplement their in-house staff.

Since transparency in government is a value I suspect that you and your agency subscribe to, I didn’t think you would object. But I also felt it fair to alert you that I am still blogging. This email will be today’s entry.

During our phone conversation last week, you agreed (1) to send me by email a list of quality assurance agencies within CMS and (2) to check with your colleague about the annual reconciliation  process for Kaiser Advantage members with mental health diagnoses that increase their risk scores.

While Kaiser claims that members identified with parity diagnoses (like Major Depression or Panic Disorder) are provided specific follow-up care through outpatient psychiatry clinics and/or behavioral health specialists, aside from an initial visit for evaluation, follow-up care is nearly non-existent. As I let you know on the phone, Kaiser Advantage members, regardless of severity of diagnosis, can only meet with their primary therapist on average once every one or two MONTHS. By comparison, Medicaid clients in California are covered to see a private therapist in the community at least once a week until their mental health condition resolves — indefinitely if it doesn’t.

Thanks again for the initial conversation. I look forward to hearing from you soon.

Andy

(43 days to go.)

Taking it to the Feds

A month ago I submitted an on-line report of suspected Medicare fraud at Kaiser using  the Medicare.gov website. I was not expecting any response beyond the automated email confirmation of receipt I got immediately. Imagine my surprise, then, when a snail mail letter dated October 23, 2014 indicated that a contract agency, Health Integrity LLC, was following up on my report. It said: “Your information will be reviewed and you will be notified of the results.” The letterhead indicated Centers for Medicare and Medicaid Services (CMS) and the letter was signed by a Complaint Specialist from the National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC).  The website for NBI MEDIC indicates that they investigate claims of fraud, including Medicare Advantage fraud. So it seems my complaint had fallen into the appropriate hands.

A week later I got another letter from the same agency, reporting: “After researching and reviewing your complaint, the NBI MEDIC has determined that issue has already been resolved by another agency therefore, your complaint will be closed and tracked in our database in an effort to identify trends with the subject of this complaint.” The letter was signed by Lisa Carson, Complaint Specialist. Of course I called up Lisa immediately. She called me back within a day, while I was on a hike with my dog Apollo in the redwoods. She let me know that the other agency, the one that had “resolved” Kaiser’s mental health care issues was the California Department of Managed Health Care (DMHC). But she knew nothing further and was not part of the investigation. She did, however, willingly pass on the name of her supervisor, Belinda Cross, and told me she would have Belinda give me a call to follow up.

I just got off the phone with Belinda who took the time to explain her agency’s role in investigating claims of Medicare fraud or abuse. She let me know that my on-line complaint started at the Office of Inspector General for Health and Human Services (OIG). It was sent to Health Integrity to see if the case has merit. If it does it will be returned to the OIG for further investigation, and, if appropriate, on to the Justice Department to pursue a remedy for the fraud. Otherwise, they’ll put my complaint in a database in which similar claims may add up eventually to a case. Then it will be forwarded to the OIG.

I told Belinda that the DMHC’s investigations and fines have, to this point, only addressed initial access to psychiatric care. How waits between visits with individual therapists across California Kaisers are 4-8 weeks. And how Kaiser bills Medicare for diagnosis-specific treatments, including Major Depression and Panic Disorder, without providing adequate treatment past the initial assessment. After a pause Belinda volunteered to investigate further, without saying she was re-opening the just-closed case. She told me she had an associate who knows more about “annual reconciliation” — a process I didn’t know existed prior to our conversation. My guess is that annual reconciliation means that once a year Medicare looks at Kaiser Advantage members who receive additional funds for expensive medical conditions (see my October 15 post) to make sure they got adequate services for the extra compensation.

If that’s the case, I would love to know how the review process operates for parity mental health conditions!

Belinda also encouraged me to pursue a complaint about quality of care with the Quality Improvement Organizations (QIO) arm of the CMS. Which indeed I will. She promised to email a link to the appropriate agencies to contact. But I’m also going to work with her to attempt to establish that Kaiser’s abuse of Medicare funds deserves attention at the OIG level. Considering the scale of under-staffing, the years that the abuse has continued, and the consequences to Medicare recipients, (past, present and future), the investigation deserves to go up the pike.

(47 days to go.)

STRIKE!

The California Nurses Association (CNA) and the National Union of Healthcare Workers (NUHW) are considering a huge conjoint strike some time in November. I wonder how they’re going to message the array of problems behind this action. Why am I concerned about the messaging? The Kaiser Medical Group (TPMG) has been fairly successful, throughout the 3-year-and-counting NUHW contract battle, in clouding the therapists’ message of poor quality mental health care in psychiatry departments throughout California. Kaiser spokespeople have been consistent, telling the media at every opportunity that therapists created a smear campaign to improve their position at the bargaining table; and that the foundation of the smear — poor client care due to long waits between visits — is a groundless manipulation. While therapists certainly are interested in a contract that keeps their benefits in place, they’re also interested in improving client care. I believe this two-part message, even after three years of delivering it, on the picket lines and in press packets, has been heard by the public only partially.

Nurses now face the same challenge therapists have been facing for years, getting their two-part message across. Kaiser’s contract with 18,000 CNA-represented nurses in California expired this summer. They are now bargaining to keep their benefits AND to keep appropriate staffing levels. In terms of benefits, Kaiser has made it clear that the takeaways offered to NUHW therapists in contract talks are being rolled out to all employee groups as their contracts come due. This fall, it’s the nurses’ turn to be offered these takeaways, and to protest or submit as they will. And in terms of cutting staff, Kaiser spokespeople are advertising that current staffing levels in the hospital are excessive and outdated, indicating they intend to change nurse to patient ratios in their contract offers. (Listen to the 10/17/14 NPR report by April Dembosky.)

It might be wise for union spokespeople (for both unions) to include an “and” in every statement they make to the press.  As in: we’re interested in maintaining benefits AND in maintaining quality patient care. Contracts can, of course, do both. Staff to patient ratios have, historically, been part of the nurses’ contract. This creates, for nurses and patients, a certain amount of protection against the HMO’s endless efforts to cut costs. By contrast, therapist contracts have never included a provision to limit the number of clients on a therapists’ caseload, nor one to contain group size. If it’s not in the contract, therapists cannot “grieve” understaffing through the collective bargaining process. Which is why the NUHW and other interested parties (like moi) have turned to HMO watchdog agencies, like the California Department of Managed Healthcare, like the US Department of Health and Human Services, instead of the National Labor Review Board, to fight for mental health parity.

Contrary to Kaiser public relations rhetoric, there is no contradiction between taking care of oneself and taking care of one’s clients. Kaiser spokesfolk continue to claim that in order to contain consumer costs something has to give — either patient care or staff benefits. But as long as the CNA and the NUHW remind the public of Kaiser’s massive surpluses (now in the billions of dollars per quarter), I believe the public will draw a different conclusion…

Maybe it’s Kaiser’s surpluses that have to give.

(Don’t get me started on CEO salaries. Did you know that the current CEO of Kaiser is not even a healthcare professional?)

I’m excited about watching this power struggle play out, and I look forward to joining my former colleagues on the picket line. We all need to do what we can to support nurses and therapists as they go up against the corporate machine. I’ll say it here, now, as a pre-amble to the festivities:

Thank you, health care professionals, for taking a stand for patient care AND you deserve just compensation for your hard work.

(64 days to go.)