So Long! Farewell!

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I started this blog at the very end of February 2014 and today’s will be my last formal entry. I can’t promise, however, that I’ll be able to suppress posting the occasional update. I’ll leave the website up at least through the end of the year since new people are coming to it every day and finding out they, too, can challenge what once felt unassailable. But, as anticipated, now that I’ve left Kaiser I need to turn my attention to my new life. So, for my own sense of closure, I’m going to consider this job done, finished, kaput!  as of today.

What has become clear over the course of the last ninety days might have been obvious to some, but came to me as a revelation. Kaiser will continue to provide inadequate mental health care until it becomes more expensive than actually taking care of people properly. To this point it has been more profitable for Kaiser to offer the appearance of care than actual care. But, thanks to the tenacious work of therapists and the National Union of Healthcare Workers (NUHW), and thanks to the continued pressure of underserved clients throughout the system and over many years, the cost of not providing care has been rising precipitously.

Fines from the Department of Managed Health Care (DMHC), individual lawsuits, class action lawsuits… they’re all adding up. And as public awareness grows about these routes to challenge Kaiser’s business model, the cost of NOT providing care will eventually exceed the cost of hiring  enough staff to provide services to the people who need them.

These last three months have been harrowing. No experience, however, has been more distressing, nor more inexcusable, than when Kaiser’s Santa Rosa Medical Center Psychiatry Department cut me off from my clients on May 8, mid-closure. It demonstrates how far Kaiser will go to protect its appearance at the risk of hurting its individual members. Please read the two entries “Close Call” and “Chelsie’s Story” to see what happens all too often when corporate decision-makers are in charge.

Kaiser Permanente is the number one treater of mental illness in the State of California. As Kaiser’s presence continues to grow outside of the State, it may become, (it already may be), the number one provider of mental health services in the country. To me this means that the therapists and mental health clients who are taking their stand now are correcting the course of managed care for generations of the majority of the country’s mental health clients.

So… be of good cheer, all! Everything is changing right before our eyes. We  just need to continue doing the right thing, speaking up and following through, for care to improve. We don’t need to be outraged, though this is justified. We just need to be persistent. Kaiser has already begun to switch course. Eventually the balance sheets will speak for themselves. Profits versus penalties will hit a breakeven, and the train will groan into reverse.

And then, my friends, Kaiser will start providing the level of mental health care needed to ease, as much as humanly possible, this human suffering to which we are all witness.

* * *

Special thanks to those who gave me courage and support through the challenge of the last ninety days:

My many-many wonderful Kaiser clients, Rita and Steve Weisskoff (good stock), the lovely Carol E. Miller (bride, and writer of the beautiful memoir, Responsible Girl, to be bought up by some fortunate publisher and released very soon, as well as the blog Diagram of a Family), Tim Carroll (predecessor as shop steward and ongoing confidante),  my many therapist, receptionist, nurse, physician assistant, psychiatrist, and security guard pals at the Santa Rosa Medical Center’s Psychiatry Department, the truly brilliant staff at the NUHW (especially Sam, Greg, Fred, Pavel, and Justin), and the courageous stewards of the IBHS chapter of the NUHW (the real heroes stay to fight the fight).

(0 days to go.)

The Devil in the Details

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.)

So…

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

Going National

The long anticipated article by Martin Espinoza came out a week ago. I was relieved and impressed by the clarity of reporting. The issues are finally being aired. I’ve also been speaking with a reporter from a national on-line press and one from KQED, the San Francisco public radio affiliate.

With national press taking a look, it’s time to frame the issue as one of failed public policy. To this end I wrote a letter and emailed it to two departments in Governor Jerry Brown’s office.

Hello Health and Human Services staffer:

Hello Consumer Affairs staffer:

I am the writer of the blog 90daystochange.com. To date it has received over 20,000 views.

On March 10 this year I sent a message to Jerry Brown via the Office of the Governor’s website that was forwarded to the Department of Managed Healthcare personnel. I am grateful that you took my efforts at improving mental health care at Kaiser seriously enough to forward that letter. My efforts continue and are gaining media attention. Sunday June 15 the Press Democrat (Santa Rosa’s paper) published a front page exposé on Kaiser mental health treatment. You may be aware of this.

As a result of this exposé, national media has been contacting me. The story I’ve been telling them is that the DMHC has not done enough to address the deficiencies in the system, that the DMHC is aware of the 4-8 weeks wait-times between individual sessions, and are hiding behind the smokescreen of an “ongoing investigation” that they are not free to comment on. And that the Governor is aware of this problem as well, since my March 10 message was received and pursued via the Office of the Governor’s website.

The implication, I’m afraid, will be that the Governor is unwilling to address the situation because of his ties to Kaiser. That he appointed the former CEO George Halvorson to the First 5 commission soon after Halvorson’s resignation is one of the facts that creates this impression.

I am not writing to accuse anyone of misconduct, but to get the ball rolling much faster than it has been rolling to get Kaiser to provide the most basic level of mental health treatment to its thousands of members in need.

As goes Kaiser, so goes the nation, so this issue is very important. Please contact me to let me know what your office and the Governor intend to do to address mental health care at Kaiser.

Andy Weisskoff, LCSW

 

Chelsie’s Story

Chelsie read me this document in my office last Friday (See “Close Call,” my previous post) and then sent it to me, requesting it be posted on the 90daystochange blogsite. We discussed the ramifications of going public with so much personal information. And she’s determined to see the system change for the sake of others in her situation. After our discussion I felt that I would be getting in the way of her self-determination if I blocked her request in the name of protecting my client.

I also had to overcome my embarrassment about so much praise. You’ll see what I mean. But, like Chelsie, I’m determined to get the whole story out, and in its most potent form.

From Chelsie…

The thing about this is, I honestly felt as if I was one of the lucky ones in the Mental Health world. Here I had an amazing psychiatrist, an amazing psychotherapist and I was growing, slowly, but growing; I was growing to learn, to cope, to accept, and to change. But this all changed when I received that call.

This call reminded me of why I do not trust people. It reiterated in my mind that NO-ONE really cares about ME. I felt stupid! My thoughts and feelings were as such: How could I have ever believed that my therapist cared about me individually when he has so many other patients, and hey after all, I am just a paycheck right? I couldn’t stop feeling like the battle in my mind was now ready for a war. I found myself in a place that took me years to get out of, and all it took was one phone call to put me right back there, maybe even further. I could not believe that I had allowed this to happen. I put myself out there, I was exposed. My therapist knew me better than I sometimes knew myself and I gave that to him, but obviously none of that mattered to him, otherwise he wouldn’t have just blew me off like dust to the wind. I couldn’t help to think of what a coward he was, he didn’t even have the balls to call me himself to tell me that he couldn’t see me anymore, instead he had someone else do it.

At this point I was angry, alone, and DONE! I am not a stranger to suicidal thoughts, obsessions, and attempts, but I found myself in the unfamiliar territory of planning. I worked out in my head the training I needed to provide to the new staff, as to not leave too much work for my boss in my absence. I was cherishing moments that I honestly felt were going to be my last with people I hold near and dear to my heart. I even found myself reviewing the Life Insurance Policy from work to see if this may help my husband and son pay off bills and help in the financial state of my absence.I had some letters completed to my loved ones, and some that were not, as I could not find the words to say goodbye to my son.

When my psychiatrist called me, I had already known at that point that I was DONE, but I didn’t want him know that. So having the appointment scheduled so far out was actually exactly what I had wanted at that point, this allowed me to have more time to complete my plan. I have a wonderful psychiatrist, but in this moment I felt so betrayed by everyone that I couldn’t risk him knowing that I was in-fact not OK.

After a few of the things that my Psychiatrist had said to me and the overwhelming image in my head of Andy’s brown shoe shaking throughout our entire last session, I felt this urge to just enter Andy’s name into Google. The first listing that came up was his 90daystochange.com blog.

After I had begun reading his blog, it became clear that he IN FACT did not abandon me as it had so strongly seemed, quite the contrary actually, he did reach out for me and he lost his job defending ME! Standing up for ME! Caring about ME! I know that sounds crazy, but the truth is, anyone who suffers with a mental illness is ME! For the first time in my life I felt like I was important and worth fighting for.

If he is willing to put it all on the line and sacrifice his job fighting for me and everyone like me, then do I not owe it to him, to my family, to my loved ones, to myself, and to everyone else suffering with this illness to stand and fight too? I want the world to know that I am never going to stop fighting ever again. I will continue to fight for myself and everyone like me because my therapist taught me how. I will live through the wars in my head, the chaotic thought trains invading all the rails in my mind, and the flashbacks that haunt me at any given moment forcing me to re-live the same nightmares and traumas of my past. I will live, and I will fight every day to give hope to everyone like me that it is possible.

The unfortunate part here is that not everyone has an “Andy” in their life helping them to see how important they really are, how much value their lives hold, and most importantly how to trust and believe that there are people in this world that want to help and are willing to sacrifice whatever they must in order to make it happen. Andy has given me so much more than I could have ever imagined, he gave me life; life by allowing me to express the emotional storms that invaded me, the irrational chaos that would sometimes devour me, the sadness that made my heart feel as if it was going to stop mid-beat when it could not take anymore, the razors I used to release it all when it became more than I could bare, the suicidal states of mind that landed me in terrible places. He let me express it all, as he listened to me and spoke to me without judgments. He constantly reminds me that I am not just crazy. He believes in me and my capability of getting better, he remains the strength in me when I can’t find the strength in myself, and here he is fighting for me when no one else would.

I have suffered at the hands of many, and as a result of that I began cutting at the ripe age of 9. I had learned that physical pain was the only thing that would take away my emotional pain. Although this relief was temporary, it was relief, a break; so to speak. My first suicide attempt was when I was 21. My son was only 4 at the time.My head had convinced me that it would be best if I was gone, and that my son would have a better chance at life without me in it.

It wasn’t long after becoming a Kaiser patient that I had intentionally overdosed on my medications. I felt as if I could not get a break. I felt like I was so severely damaged at this point that I just wanted to sleep: Forever.

People have a tendency to believe that we are capable of dealing with our mental illnesses on our own, that we don’t need help. But I am here to tell you different. I needed help, I still need help, and I will probably need help for the rest of my life. I wish that people would see mental illness as they see other illnesses. I mean really, telling someone with a mental illness to “Get Over It”, or “Stop Being Like That” is LITERALLY like telling someone who’s diabetic to “Produce Their Own Insulin” or telling a paraplegic to “Get Up And Walk”… It’s not realistic, yet it’s not different at all.

You see, we don’t convince people that we are fine simply because we are unwilling to seek help. We do this to protect ourselves, because allowing people to know our true selves leaves us exposed and vulnerable. We are not capable of depending on people because it is people that hurt us to begin with. We are constantly waiting with our guards up in anticipation that harm is coming our way.

Some of the phrases I have heard through my suicidal crazes are “You’re Selfish” or “You’re Weak”, but here is something to ponder: Does living in a mental hell so that you don’t have to hurt, make me selfish? Does waking up every day only to re-live the same terrors and traumas that have haunted me all my life, make me weak? I know I am not “Selfish”. I know I am not “Weak”. But most importantly I know that I need help and that I cannot do this alone, no one can. This is only a small example of how we can rationalize any situation, so choose your words wisely to those you love. These were usually the type of words that helped make it easier for me to want to follow through in my suicidal ideation.

I want to say thank you Andy! Thank you for being such an inspiration to me and everyone like me, and giving us hope that there are people out there that care about us. Words could not begin to express my gratitude to you. I will stand by you through all of this and try to pay forward what you have given me, my family, my friends, and everyone like me; HOPE!

Chelsie Martinez

(2 days to go.)

Close Call

I just met with one of only four Kaiser clients so far who have found their way to my private practice office. She let me know that on May 8, the day I was escorted from the building and all my remaining appointments with about twenty clients were cancelled, she was contacted by a receptionist. Not by a clinician. The receptionist told her that I was “‘unable to see any more patients.’” My client interpreted this message to mean that I had gotten too busy in my last days at Kaiser, and that I had asked the receptionist to call my clients and let them know this, that I couldn’t be bothered to do it myself.

In the same phone call, she was told she would be contacted in a week to arrange an appointment with her psychiatrist to discuss future therapist options. This is a person with a Major Depression, Recurrent diagnosis, with a fairly recent psychiatric hospitalization for a suicide attempt. She was called back on 5/13 (as promised) and a receptionist set up an appointment for 6/2. The next day her psychiatrist checked in with her and asked if 6/2 would work or if she needed something sooner. She told him the date he had set was fine.

She said the date was fine because she planned to be dead by then and didn’t want to be talked out of it.

I’ve been working with this client for a lot of years — four, maybe five – and we have a strong therapeutic bond. But, like many of our clients, her sense of self-worth is very fragile. It doesn’t take much for her to feel unloved and to give up on life. In our last meeting at Kaiser, I had told her that I was leaving soon and going into private practice. I had let her know that I would be happy to see her there, and on a sliding scale to accommodate her income. That was the plan. Yet, when she got the call on May 8, worded as it was, and coming from a receptionist, kind-hearted though they are, she still felt abandoned.

She told me she thought she wasn’t important enough to warrant a phone call from me directly. She told me that after the call, she started to come up with a plan to kill herself. She had made impulsive attempts before, with cutting or pills, but this plan was different. She was determined to make it work. She started writing letters to the important people in her life. She stepped up the training of one of her workmates so that that person could take over when she was gone.

By a grace of the gods, something shifted inside her. She remembered the last time we had met, how I was unusually preoccupied and bouncing my leg nervously and uncharacteristically. It made her curious. She Googled me and got to this blog site. She read the whole thing.

She found out that I was no longer working somewhere in the building, ignoring her. That I had been kicked out. That I was trying to contact my former clients to help with their transitions either to new therapists at Kaiser or to me in private practice. She called immediately and we talked. She said that she was really upset, that the process had messed with her. But she also set up two weekly appointments before the end of the month, today’s being the first. During today’s meeting we agreed to meet every other week after that on a sliding scale she can afford.

By the time our session ended, Kaiser was closed for the three day weekend. I just left this message on the voicemails of Brigitte Dunn, MFT, and Mark Bender, PhD, my former direct supervisors. I scripted it out so I could say what was important — since my mind is spinning right now — and so that I could have a record of what I had said. Then I copied the message and sent it via email to their work addresses. Just to make sure it gets there.

I said, “I’m calling at 8:30 Friday, May 23. One of my Kaiser clients let me know today during a private practice session that on May 8, when she was called by a receptionist, and her last appointments with me at Kaiser were cancelled, that she believed that I was still working there, but had made a choice not to see her.

“As a result of this abandonment she started planning and came very close to executing her plan to kill herself. She would have gone through with her plan, if not for the luck of coming upon my blog and reading it.

“I’m leaving this message for you two because I’m holding you personally responsible for calling every single one of my clients, the ones I was scheduled to see through the end of the month, and letting them know that I no longer work for Kaiser and that I want to see them. Give them my direct line (707) 799-4125.”

Even if there are no deaths as a result of Kaiser’s careless handling of these fragile people, what misery to put people through!

And for what?!

(7 days to go.)

Talking to Martin

This afternoon I met with a reporter from the Press Democrat, the Santa Rosa newspaper, and got to talk about what’s been going on locally, at the Santa Rosa Medical Center’s Department of Psychiatry, and throughout the State. He seems interested. I hope this is the start of the story going national. I was so nervous, (I forgot my home address and had to look outside my door to tell him where to meet me), that I worry now I didn’t present what’s crucial clearly. But I get to speak with him some more tomorrow. And he’s going to ask Kaiser the basic questions: Why did you resign this guy early? (And) What are your standards for providing individual psychotherapy?  I’m very curious to see what they say. I doubt they’ll say anything.

Justin, my press contact at the NUHW, suggested I try writing another editorial, an updated version of the ones I sent to the Times and the Chronicle, to capture the excitement of being escorted from the building. They’re looking to spread the story using a variety of venues and every bit of drama helps. I came up with this:

When I got to my office in the Kaiser Santa Rosa Medical Center on May 8, my computer wouldn’t let me log on. I was similarly locked out of my voicemail. Within minutes I was brought to the Chief of Psychiatry’s office and told “your resignation is being accepted as of today.” I was relieved of my keys and badge and escorted from the building. I was told that my remaining psychotherapy clients, the ones booked out until my actual resignation date three weeks later, would be “taken care of.” There was no room for any sort of discussion.

I’ve been a Kaiser therapist working with adults with mental illness for the past 7.5 years. Three months ago I discovered that I could no longer, in good conscience, continue. Over the course of the previous year the time available to see our clients one-on-one had deteriorated from inadequate to completely unacceptable. The typical wait time between visits with my clients used to be three weeks. After the first of this year, however, it stretched to six weeks. I decided it was time to leave and open up a private practice.

In the three months I had left, I was going to use the resources of an insider to make public the scope of Kaiser’s mental health service delivery problem. I started to blog at 90daystochange.com, (which to date has received 16,000 views), publishing my perspective and documenting my attempts to improve care within the largest HMO in the United States.

For the entire time I’ve worked at Kaiser, individual psychotherapy has been a very low institutional priority. Until the Department of Managed Health Care (DMHC — the government agency that monitors HMO services) stepped in two years ago, Kaiser Psychiatry Departments state-wide felt free to announce “we don’t offer individual psychotherapy.” At all. After being fined $4 million, Kaiser stopped saying they don’t provide individual psychotherapy, but they today provide even less individual care than they did before the DMHC stepped in.

By communicating with therapists throughout California, on my blog and at steward council meetings at the National Union of Healthcare Workers (NUHW) office in Emeryville, I discovered that understaffing is universal. Since February this year, the average wait-time between individual sessions at Kaiser clinics throughout California has been four weeks. Kaiser “justifies” this appalling lack of service by balancing the cost of hiring more staff against the relatively cheaper cost of settling malpractice suits out of court through their binding arbitration process.

Through DMHC fines, and through class action suits brought on behalf of clients who have had to seek care outside of Kaiser, the cost/benefit analysis is shifting. As more people learn that they can hold Kaiser accountable for their lack of care, the cost of not providing meaningful treatment will rise. Sooner or later, Kaiser’s going to say: it’s cheaper to treat people than not to.

For the sake of the thousands of Kaiser members with mental illness not being served every day, I hope it’s sooner.

(11 days to go.)

Never Can Say Goodbye

I spent the last three days driving back and forth to San Diego, past terrifying brush fires visible from the freeway, to retrieve my daughter after her first year of college. A bit of drama for a change.

A brief update…

Of the twenty or so clients I was working with when escorted out of my office on May 8 — more than a week ago — only three have contacted me. I’ve booked “free” closing sessions with these three in my private practice office and am grateful to finish with them as intended. They found out about my offer through their own research on the web, or in one case, from a psychiatrist following his conscience. I have yet to hear from the people I was in the middle of working intensively with, using EMDR to address their childhood trauma. I’m sure they would have called by now if someone had let them know I was available.

A reporter for the Press Democrat, Sonoma County’s daily, wrote a few days ago to ask if he could interview me this coming Monday. I, of course, said yes, but am still waiting for confirmation of date and time. Nationally, there’s been a lot of interest in mental health services as a result of the VA scandal breaking in the past week.  Also last week, USA Today published the first in what they announced will be a series of stories about the current state of mental health treatment in the United States. Maybe, after three years of therapists attempting to raise these issues on a national level, Kaiser will be next to draw some media attention for their inadequate standards of care.

My farewell party is going forward as planned in a week. Off-site, of course.  I’ll  get the chance to celebrate with my colleagues the end of a good fight. I’m really looking forward to that.

But it would be extra extra nice to end the ninety days with some national press. Don’t you think?

(Lucky 13 days to go.)