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 In the first case, Kaiser lawyers must have withdrawn because they knew they couldn’t prove Kaiser mental health administrators had responded to the DMHC’s allegations sufficiently or quickly enough.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.)

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 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.)

Doctors v. Lawyers

At the same time as trying to get the agencies that oversee Medicare to penalize Kaiser into providing parity mental health care, I’ve been curious about the potential of medical malpractice lawsuits to force the same change. To that end I’ve been sending emails to personal injury law firms in the Bay Area that specialize in medical malpractice — some even advertise that they hyper-specialize in Kaiser cases. I’ve been offering my services as a consultant or expert witness. I think I can help lawyers develop an argument that the structure of mental health treatment at Kaiser puts all patients at risk. I can also guide them to the kinds of questions that will demonstrate how this faulty structure led to their particular client’s bad outcome, e.g. suicide, hospitalization, loss of a job or a significant relationship.

By bizarre coincidence, there’s an initiative on this November’s ballot in California to increase the cap on medical malpractice payouts. Since the relatively low cap seems a barrier to influencing Kaiser’s policies, I wrote an editorial in favor of raising the caps and sent it to the LA Times, the San Francisco Chronicle, and the Sacramento Bee. All three have declined to publish it. I’ll send it to the Santa Rosa Press Democrat today, but thought it might be helpful to post it here.

Here’s what I wrote:

With seven million members in California alone, Kaiser Permanente is the state’s number one health care provider. That makes them the number one provider of mental health care too. One painful truth about mental health care at Kaiser today is that, with current caps on malpractice awards, it’s cheaper for the HMO to litigate a suicide than to prevent one. Consequently, significant flaws in their treatment programs go unaddressed year after year. As a psychotherapist who until recently worked within the Kaiser system, I believe an increase in the cap on malpractice lawsuits, as proposed in Proposition 46, could help steer the system toward competence.

From September 2006 until I was escorted from my office for whistle blowing this past May, I evaluated and treated Kaiser Permanente members with mental illness at the Santa Rosa Medical Center. During my last three months at Kaiser, I blogged about the myriad and widespread deficiencies in the managed mental health care system on my website 90daystochange.com.

First off, I argued, therapist staffing levels are unconscionable. Across California, the wait between one-on-one visits with a psychotherapist — the core of treatment — averages four weeks. Due to the absence of individual attention, the drop out rate for people with major depression and panic disorder, two of the most common conditions in psychiatry, is 75% or more within the first three months of treatment.

At the same time, quality assurance programs are grossly insufficient and out of compliance with state and federal laws. Quality assurance programs are a fundamental check on HMOs. Without them, specific provider problems (like incompetence) or system problems (like understaffing) continue unabated. Last year the panel of four therapists in Santa Rosa who conducted internal reviews of suicides and other negative outcomes was reduced to a single physician charged with reviewing all cases. Since physicians own the medical group, delegating quality assurance to an MD alone creates a dangerous conflict of interest.

Considering the breadth of these staffing and quality assurance problems, penalties from state and federal regulatory agencies have been slow and slim. After three years of campaigning, the union representing Kaiser therapists was able to leverage the California Department of Managed Health Care to fine Kaiser’s physician’s group TPMG $4 million. Four million dollars would pay for twenty-five new therapists for a year. But Kaiser California needs at least a thousand more therapists to make even a dent in their service gaps. In order for executives at the top to re-examine their bottom line, a fine would need to be more on the order of $100 million a year until the situation is resolved.

Since the feds and the state are unwilling to levy effective fines, individual lawsuits need to become a more prominent force for change. Raising the cap on penalties would bring increased numbers of lawyers and families to the arbitration table. As more compelling evidence about gaps in Kaiser’s treatment programs continues to emerge, family members will win these cases more consistently. The cost of litigation will go up.

And, eventually, Kaiser’s cost-benefit analysis will guide their executives away from litigation and towards care.

(72 days to go.)

Let’s Talk Medicare Fraud

According to the Kaiser Family Foundation, in 2013 Kaiser had 8% of the Medicare Advantage market. That means that last year 1.1 million elderly and disabled Americans received their health care, including mental health care, through the Kaiser Advantage program. Medicare recipients get their care side by side with other Kaiser members whose premiums are paid by employers or privately. All of the deficits in care I observed while working as a therapist at Kaiser from September 2006 through May 2014, documented in the first “90 Days” of this blog, apply to Medicare patients too.

When a Medicare beneficiary chooses Kaiser as its provider, Medicare pays Kaiser a monthly premium on behalf of the beneficiary in expectation that the consumer will get a basic level of care. Medicare also pays additional fees as incentives for Kaiser to treat “sicker” patients. I read about the abuse of this additional fee system in an article by Fred Schulte of the Center for Public Integrity in Washington DC. He reports that Medicare Advantage patients get higher “risk scores” if they have diagnoses that lead to more expensive care, like hypertension. Like Major Depression, Recurrent. And higher risk scores translate to higher reimbursement rates that Medicare pays Kaiser, presumably for additional care.

According to federal parity laws, Kaiser is compelled to provide basic mental health care at a level comparable to physical health care, to all its clients, including Medicare clients. With the risk score system, Kaiser accepts additional funds to provide additional care for people with mental health diagnoses like Major Depression. But Medicare beneficiaries aren’t getting additional care. They’re not even getting basic care.

I made the argument in the first “90 Days” that Kaiser does not provide the most basic services expected by consumers and therapists, let alone parity services. The most standard treatment protocol in the Kaiser mental health model of care is a single hour of initial assessment, followed by referral to a skills group, with a follow-up one-on-one therapy appointment booked typically a month in the future. The drop out rate from the skills groups for major depression and panic disorder (two of the most utilized treatment tracks) is 75% or higher. Without the support of an individual therapist who meets weekly for at least the first month of treatment, most (75% or more of) new clients get discouraged and drop out.

Kaiser might claim that an initial drop out rate of 75% is par for the course for mental health treatment, and that this high rate doesn’t prove they need to hire more therapists. That might be a credible defense if they had a meaningful quality assurance program, as required by law, to back up the claim.

Last year in Santa Rosa, a fairly functional quality assurance panel of four therapists was replaced by a single MD reviewing all cases of suicide, near suicide, and other poor outcomes. I say it was fairly functional because it was always unclear how cases came to the panel for review. The two cases of suicide in which I had been one of the providers involved did not come up for review – at least not by the panel. In an effective quality assurance system, every single suicide would be reviewed by a multidisciplinary panel to assess for provider and system flaws. To prevent future bad outcomes.

The panel in Santa Rosa was de-authorized in an attempt to staunch the flow of damaging information to therapist whistle blowers. Kaiser does not want therapists to have precise information about the actual numbers of suicides in the department, nor to be party to the evidence that might demonstrate that suicides can be  linked to the current model of care — brief assessment and referral to groups.

These two deficits — a defective treatment model and the absence of meaningful quality assurance checks on the model — taken in tandem, result in a gross misrepresentation by Kaiser of the care paid for by the Medicare program. In 2013, as many as 1.1 million Americans were affected by this misrepresentation. In other words, Kaiser has been committing fraud, year after year, on an enormous scale.

To restate: our tax dollars are being given to Kaiser to take care of the health, including the mental health, of Medicare members. Extra money is being paid to Kaiser to care for people with certain mental illnesses. The money is being spent on programs that licensed providers within the system are calling insufficient at best and malpractice at worst. And the mechanism of quality assurance, the check on an HMO’s natural inclination to cut costs, exists in form only.

If that’s not fraud, what is?

(76 days to go.)