Just added to the media storm clouds gathering is the first in a series of articles by KQED blog writer Jon Brooks, who, like Martin Espinoza of the Press Democrat, has been reporting the story of Kaiser mental health in a balanced way sure to bring the facts forward. In his July 1 report, Brooks quotes Dr. Mason Turner, Kaiser’s director of patient operations for mental health in Northern California. Dr. Turner, here, is speaking to the issue of delays in individual therapy follow-ups:
“’We would expect our therapists, if they thought (a patient) needed to be seen sooner, would elect to discuss it with their manager and look for alternative times… we have ways of accommodating this when it comes up.’” [parentheses Jon's, ellipses mine]
Turner’s assumptions imbedded here are (1) accessibility of individual therapy hours are adequate in the vast majority of cases, and (2) in the rare instance where a client needs to be seen sooner than the therapist’s next available appointment, there are systems in place to accommodate that need.
From the therapists’ perspective, rare is the case when a client does NOT need a sooner individual follow-up appointment than the next one available. And when a therapist wants to see a client sooner than their next available one, (i.e. almost every time), no amount of discussion with a manager can make a sooner slot appear.
I wondered what the Department of Managed Healthcare (DMHC) was thinking about these statements of Dr. Turner’s. I sent a message to Marta Green, Communications and Planning Director at the DMHC, asking why the two week maximum rule for non-urgent appointments (the regulation used to fine Kaiser $4 million for delayed initial access) isn’t being pursued for follow-up appointments. In her brief emailed response she thought it important to clarify one thing:
“Keep in mind,” she wrote, “that if a referring or treating physician or triage professional determines, using professionally recognized standards of practice, that a longer waiting time will not have a detrimental impact on the health of the enrollee, the waiting time may be extended.”
I assume she specified this caveat to timely access because Kaiser is using it to justify longer than 10 day wait times between individual appointments — that a routine practice of extending the wait doesn’t have a negative impact on their members’ mental health.
To her email, Marta attached the relevant section of law, “1300.67.2.2. Timely Access to Non-Emergency Health Care Services.” I’m grateful she did. Because the law spells out the flaws in accepting Kaiser’s justification. The actual law reads, from section c, 5, G: “The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider…has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee;” [ellipses and emphasis added by moi].
The law states it is up to the individual provider to assess how soon the follow-up appointment needs to be. And, if a provider is going to work outside of the two week maximum standard, s/he must record in the chart justification for doing so.
In February 2014, when I started tracking return availability of adult team therapists in Santa Rosa, not one of the 19 had a return appointment within the two week time frame. According to the law, every single follow-up appointment booked that month required a charted explanation of why the client was going to be seen outside the two week target. Needless to say, the number of such chart notes during that time period was ZERO. I don’t know if any Kaiser therapist at any time has ever written such a note.
(Ironically, when I started charting the opposite phenomenon – my concern that a timely appointment was NOT available and that I thought the long wait WOULD have a detrimental impact on the health of the enrollee — I was relieved of duty.)
I sent the following email to Marta today:
Thanks, Marta, for sending me clarification of the timely access regulations, in particular for bringing my attention to the legal caveat for operating outside the 10 business day limit for non-urgent mental health visits. It leads me to a few questions I hope you can take a moment to address.
My reading of the regulation — section c, 5, G of Article 1300.67.2.2. Timely Access to Non-Emergency Health Care Services — is that the individual provider, not the Plan or its managers, gets to determine what the member needs in terms of follow-up care. Is that how the DMHC would characterize the law?
Therapists as an aggregate have been reporting to the DMHC that they usually recommend a combination of individual and group follow-up, but cannot book members for the individual follow-up portion within thirty days, let alone the ten business days required by law. What is the DMHC’s assessment of Kaiser’s compliance with this regulation?
The same regulation specifies that providers must have “noted in the relevant record” any time they book someone outside the ten business day timeframe. Is it the DMHC’s assessment that Kaiser is in compliance with this part of the regulation?
If Kaiser is saying that a group visit qualifies as a follow-up, so that referral to a group that meets within two weeks qualifies as meeting the regulations, does the DMHC agree with this line of thinking? What if the referring provider believes the client needs access to BOTH the skills group and the individual session, to avoid a detrimental impact? Don’t both need to be available within the 10 business day timeframe?
I appreciate your attention to these critical questions.
Andy Weisskoff, LCSW