Hello I Must Be Going
Posted on February 28, 2014 by weisskoff
I haven’t been sleeping well for two, maybe three months. With each sleepless night the source of this insomnia becomes clearer, along with the only reasonable path to peace of mind. It’s time to quit my job.
I’ve been a psychotherapist working for Kaiser Permanente for more than seven years. Throughout, it’s been a struggle to provide the kind of therapy I’m designed by training and constitution to practice — EMDR. In the last month the obstacles have become insurmountable. And now it’s time to leave. This week I gave three months notice. It will take that long to safely finish the work I started with the people already on my caseload. EMDR, like most effective therapies, is dependent on the relationship between client and therapist. No one else can finish this work for me.
Quitting Kaiser is not easy. Last year, in 2013, I grossed $107K, a social worker salary unparalleled in Sonoma County, California, where I live. Private practice will not yield that kind of money. And I feel very guilty about leaving my fellow therapists and clients behind. Two months ago I took on a leadership role in the clinic by volunteering to be a shop steward. Now I’m abandoning ship.
Why am I giving up after only two months of stewarding? Why am I turning in my resignation?
Because I’m an EMDR therapist, through and through. I started using the eye movement therapy developed by Francine Shapiro as my primary modality in 2005. When I joined Kaiser a year later, there was enough time to provide EMDR safely to adults with severe trauma. No longer. My next available appointment is in six weeks. Six weeks! In EMDR, the therapist judiciously brings up the most dramatic, awful moments in a person’s life. It’s unethical to bring this stuff up without having the ability to see the person again within a reasonable timeframe. Six weeks is not reasonable.
I’ve thought many times about surrendering, doing only what the current model of care at Kaiser allows in most clinics — assessment and referral. But if I surrendered, there would be no more of the work I love to do best, the work my clients truly benefit from. Instead, I’ve decided to get busy advocating for a comprehensive shift in the delivery of mental health care within managed care. I’ll speak up in any forum I can tap into, starting from within the clinic, but on up to the Department of Managed Health Care where the real power for change resides. The DMHC is the state’s watchdog agency that a year ago handed Kaiser a $4 million fine for not providing timely access to care.
I’ll do all I can with the time I have to improve the situation for the mentally ill clients who need it and for the dedicated practitioners who are poised to help them. I’ll do it with humor. With kindness. With the leverage of the union. I’m counting on my position as steward affording me some protection against the expected backlash. The best protection, however, is public awareness. So please spread the word about this blog. It would have been nice if more people had known the name Karen Silkwood before she blew the whistle.
Ninety days to change. How much movement toward a more compassionate, more effective model of care can I promote in the three months before I leave? How willing will Kaiser be to lead the radical shift that people suffering with mental illness need?
Let’s find out.
How to Change the System-Part 1
Posted on March 1, 2014 by weisskoff
You start with the National Union of Healthcare Workers. I love these guys! The NUHW began representing most of the psychotherapists at Kaiser three years ago. They splintered off from the UHW, our previous union, in the context of stalled contract negotiations and allegations that the UHW leadership was “in bed with Kaiser.” The story is well told on their website, http://www.nuhw.org, so I won’t repeat it here.
Once the NUHW entered the conversation about how Kaiser provides mental health services, everything changed. They began by encouraging therapists to identify flaws in our systems of care. They wanted to make these flaws public in order to strengthen our position at the bargaining table. Pretty quickly they honed in on initial access. Initial access is the time it takes for the consumer to meet with a provider after requesting an appointment. State laws are murky about how frequently a client is seen once in the system. But the law is crystal clear about the maximum time allotted to get people in the door. The rule in California is 10 business days for a non-urgent appointment with a therapist and 15 business days to see a psychiatrist.
Before the NUHW got involved, very few clinics were meeting even the spirit of these laws. But to make it appear as if we were, clinics were employing a variety of strategies. Kaiser kept low the number of triage staff that were screening requests for first time appointments. This drove many potential clients, frustrated by phone tag, to seek help elsewhere or not at all. We also discouraged new clients from entering the system by saying, “We don’t provide individual psychotherapy,” and offering referrals to community therapists (that Kaiser didn’t pay for). We also had waitlists, and didn’t count the time on the waitlist as part of the 10 or 15 days.
Enter the NUHW. They interviewed Kaiser therapists throughout California and wrote a white paper in the Fall of 2011 summarizing their findings. The white paper, understandably, got a lot of press. I like The Nation’s coverage of these events, including some very large-scale strikes: http://www.thenation.com/article/164772/kaiser-permanente-workers-choose-sides. Following the release of the white paper and the immediate media storm, there was a very brief pause. And then…
Enter the DMHC. Though it conducts surveys only every three years or so, the Department of Managed Health Care chose January 2012 to commence “a routine survey” of Kaiser’s entire health care delivery system. They emerged with stark conclusions about our mental health services. Their findings confirmed what the white paper had asserted, which came as little surprise to us. (Their investigators interviewed the same therapists who developed the white paper in the first place.) The DMHC announced that all the strategies we had been using to hide actual access intervals were to stop immediately. They gave Kaiser six months to address the issues. Six months later, when Kaiser had not come close to remedying the situation, they were fined $4 million, and threatened with more penalties if they didn’t fully comply.
Then things started changing. Five new therapists, a thirty percent jump, were hired in our clinic. New policies and procedures were put in place to measure access intervals more accurately, which made apparent how far behind the laws we were. In order to get people in within 15 business days, psychiatrists in Santa Rosa had to start working overtime. They became more and more exhausted. And pissed at the therapists. (Because of our union protection, therapists only work our contract hours.) But we did have to transfer some of our follow-up appointment times to meet the demand for first time therapy appointments. For years, the time between visits for my clients had held at 3-4 weeks. Now it was drifting to 4-5 weeks.
By January 2014 the Santa Rosa clinic was doing well with the initial access targets. We were getting people who wanted to see a psychiatrist in within three weeks, and people who wanted to see a therapist in within two weeks. We all had less and less return appointment time, but the DMHC had said nothing in their report about seeing people more than once.
Then… enter Covered California.
(89 days to go.)
Don’t Worry, Be Happy
Posted on March 2, 2014 by weisskoff
In the run-up to announcing my departure from Kaiser and preparing to write “90 Days to Change,” my stress level found its way up an extra notch. Like the guy from Spinal Tap, it turns out my amp goes to eleven. It wasn’t bad enough that I was carrying the burden of trying to treat my Kaiser clients without the time to do it. Now I feel like I’ve taken on the responsibility of changing the entire system within three months. If I’m going to last until June, I better quit thinking this way. I am by no means alone. I have thousands of colleagues doing their parts, moving the conversation forward. So, I’m going to try to breathe a little easier. We all can. We’re on this road together, mid-change, and the transformation isn’t going to stop now that the ball’s in motion.
The way we’ve been providing mental health services within Kaiser is changing rapidly. These changes started three years ago with the help of the National Union of Health Care Workers (NUHW). Now the changes are coming fast and furious. Still, it may take another three years before the system is overhauled. When that’s done, the public’s expectation of how managed care should treat people with mental illness will be completely transformed.
I was encouraged by a story I heard at an NUHW steward council meeting. A therapist at one of Kaiser’s mental health clinics has begun refusing to see new clients. She told her bosses that she has a responsibility to care for the people already on her caseload, and can’t do both. Her bosses gave her some flak initially, but seem to be unable to stop her from following her ethics.
With that kind of bravery among us, we’re going to succeed. For further encouragement, check out how one of the Board of Directors for Kaiser just resigned due to conflicts of interest.
The NUHW brought the facts forward and now this very powerful person is resigning.
Warms my turbulent heart.
(88 days to go.)
How to Change the System-Part 2
Posted on March 3, 2014 by weisskoff
I sent this letter just now to my bosses (B), my bosses’ bosses (B2), and my bosses’ bosses’ bosses (B3), three tiers of administrators within the Kaiser Santa Rosa Medical Center. The B level managers are therapists. The B2 and B3 level each have MD “Chiefs” and non-MD administrators. I was pretty nervous sending it out.
As you may know, I have resigned my position as a therapist on the adult psychiatry team. My supervisor has accepted this resignation and informed me I am permitted to work through May in order to finish the EMDR work I started with patients on my caseload. I will also be retaining my position as NUHW steward until my departure. In the time I have left here I am devoting myself to improving the system to better serve our patients and staff.
For the seven plus years I’ve worked on the adult team, the therapists and patients in the clinic have not been given the opportunity to form a therapeutic alliance, the primary tool we use for promoting change. We’ve been meeting people once, for an initial assessment, and then making them wait at least three weeks before we can see them again. With the introduction of Covered California members, that wait has gotten even longer. The more impaired of our patients bounce around from one urgent appointment to the next without having the benefit of a stable advocate. Less acute clients receive so little individual support that very few access our excellent skills groups. Only half of the patients referred to one of our groups from an initial assessment make it to even the first session of the group, half fewer make it to the second. The idea that the current system works for most of our people is just not true.
I have started blogging to chronicle my efforts at bringing these concerns forward. I have no intent other than to improve services for our patients with mental illness. I do not mean to shame or blame anyone. My goal is to create the kind of leverage that promotes positive change for the clinic. I have been advised by the NUHW’s legal team that my right to speak up on these matters is protected.
In the past, the Psychiatry Department in Santa Rosa has been the model of care for treatment for people with mental illness. We can regain that status by collaborating toward a new structure for service delivery. Among our staff you will find no shortage of energy to make positive change happen. But it will take the participation of the entire medical center to make it possible. Please join us in achieving these goals.
Andy Weisskoff, LCSW/NUHW Steward for the Adult Team
(87 days to go.)
The Things They Carried
Posted on March 4, 2014 by weisskoff
Because we can’t see our patients in a timely fashion, they are at-risk for all kinds of bad outcomes. I got an idea in the shower this morning about how to portray the depth of the problem to the greater public.
Imagine a photograph alongside a newspaper article. Kaiser mental health workers on strike. The image shows two therapists side by side, one facing the camera, one with her back to the camera. Each wears a placard. The message on one side, worn by the therapist facing the camera reads: If you see me today, I can’t see you again for 6 weeks. The one on the therapist with her back to the camera reads: Even if you’re thinking of killing yourself.
I imagine us all walking around, picketing with these placards, carrying this heavy wooden burden. Because it is a burden. When I see someone today with suicidal thoughts, (often labeled “passive” to indicate there is no active planning, no collecting of pills or buying of guns), I am often uncertain how well they’ll fare in the intervening weeks. It’s a heavy load for us therapists. We care about our clients, even after one session. Did I miss something in our hour-long interview? Did I make a bad judgement call? Maybe I should have sent them to our intensive outpatient group instead of a skills group designed for people who are higher functioning.
And then I wait, at least a month, to see if my intuition, one way or another, was correct.
Kaiser has been dragging its feet in negotiating a new contract with the NUHW-represented therapists. Because we’re out of contract, we can strike. We need to give ten days notice, but we can strike. In Santa Rosa many of us voted that we were willing to enter into an open-ended strike if necessary. And I know from our stewards council that many other Kaiser mental health clinics have staff similarly ready to walk out. Maybe this idea of wearing placards could be galvanizing.
Even as I say this I’m torn. Imagine someone in distress, maybe even thinking about suicide, who has never spoken to a therapist before. On the eve of calling in to make an appointment, having found the courage to take that great risk, they come upon an image in the newspaper that deflates their courage. And just give up.
The whole thing is so sad. We must find a way to do better!
(86 days to go)
Kaiserized No More
Posted on March 5, 2014 by weisskoff
I met about eighty new colleagues in my first few days working in Kaiser Santa Rosa’s Psychiatry Department. The most common conversation starter, after simple introductions, was a question to me. “Have you been Kaiserized, yet?” This sweetly cynical term refers to the inevitable process of lowering one’s expectations to fit the realities of managed care.
During my first year I wondered if I was becoming Kaiserized. The most challenging issue to adapt to was the scarcity of time. Time to meet with clients, to consider a differential diagnosis or plan their care. Time to consult with colleagues about complex cases. Time to take notes and make phone calls and read e-mails. Time to eat. I was certainly time-pressured. But I didn’t feel the system was forcing me to compromise what I wanted to do. I had meaningful sessions with interesting clients in the privacy of my own office. I found a way to work within our scheduling constraints to use EMDR, the therapy best suited to me and my clients.
But there was a dark side to my day to day work that has always made me uneasy.
At least once or twice a month I meet with someone who is not doing well. Someone very distressed, depressed or agitated. Something has happened in their life that they can’t cope with. Or their chronic emotional problems have taken a sudden turn for the worse. They don’t meet the criteria for psychiatric hospitalization, imminent danger to themself or others, so they don’t need that level of care. But they need something and they need it from me. My instinct is to see them face to face again within a week. But my next available appointment has been 3-4 weeks away. Recently it’s up to six. The groups we run for people in this category are often not what a person in emotional distress wants or can tolerate. But they’re all I have. I don’t have more of myself. I make my referrals, schedule an appointment in a month, and cross my fingers that I’ll see them again.
I used to leave these encounters queasy, with the sense of pressing unfinished business. But over the years, whether or not I worried during the interval, the clients kept living through it. They returned to my office or dropped out of treatment, often politely with a phone call. Eventually I learned to quit worrying.
And that’s what it means to be Kaiserized. Our clients are not safe during that interval. It’s not safe for people in distress to meet a clinician once, get referred to a skills or crisis group, and then have to wait weeks or months to see the same clinician again. But the longer I worked for Kaiser, the safer the situation seemed. These unstable clients weren’t somehow becoming safer. I had just gotten used to the danger.
When the NUHW pulled off the miracle of getting Kaiser to improve initial access, (see How to Change the System – Part 1), I was transformed, as were many of my colleagues. Overnight we became un-Kaiserized. Kaiseroozed. We started thinking in terms of what our clients need, rather than what managed care claims as its limits. We started thinking, once again, of the primacy of the therapeutic alliance. Without it, nothing good can follow. With it, all kinds of positive change is possible.
Now that we’re getting Kaiseroozed, it’s our responsibility to determine the essential services our clients need and to bring these needs forward. First, to the Department of Managed Health Care, where we’ve had such recent and extravagant success. We need no longer take on face value that Kaiser can’t afford to provide basic mental health care. When Kaiser was fined $4 million, they found a way to fix the previously unsolvable problem of initial access. If their bottom line gets threatened, they’ll find a way to provide basic mental health services to our people.
We just need to define ”basic mental health services” and send our thoughts up the pike.
And then we have to fight for them.
(85 days to go.)
Posted on March 6, 2014 by weisskoff
Soon after the white paper came out in 2011, (see How to Change the System-Part 1), our local administration caught on. We, the therapists, were the whistleblowers. Over the next year in Santa Rosa, our bosses methodically cut us off from any information that might lead to further whistleblowing. The results have been catastrophic in terms of patient care.
We once had a variety of interdisciplinary committees that addressed the dynamic needs of the clinic. We had a program development committee, for example, which included MDs and therapists. We would get together quarterly to discuss emerging or declining clinical populations and to develop strategies to meet their needs. After the white paper, the program development committee was dismissed. What our patients needed was no longer the therapists’ business. Our bosses would be making the assessments and appropriate adjustments from now on.
Then there was the quality assurance committee. The QA committee was charged with reviewing bad outcomes, to look for clinician errors and system-wide deficits. In psychiatry, a bad outcome is either a hospitalization or, of course, a suicide. The committee was comprised of physicians and therapists. We used to interview all the staff involved in a QA case and disseminate conclusions to the larger community of clinicians. System wide deficits were addressed. Individual mistakes were discussed, non-punitively, directly with the practitioner in order to improve their ability to care for future clients. Overnight, this committee too was disbanded. It was replaced by a single psychiatrist whose process for case review has yet to be defined to us. As far as we know she may do nothing at all.
Somewhere in this information blackout, our adult team leader, a consummate clinician and creative engine for program development for decades, was forced out. I know she fought these changes behind the scenes, but could do nothing against the weight of the corporation. I’m happy to say she’s happier elsewhere. But the effect of losing her was gut-wrenching.
In their effort to keep us from building arguments for more staff, our bosses have cut us off from each other in ways that endanger our clients. One of Kaiser’s favorite selling points is our communication across disciplines, departments and even across medical centers. But within our department, even about these critical ways to ensure quality care, psychiatrists and therapists no longer talk to each other.
And we’re right across the hall.
(84 days to go.)
Communication Breakdown-Part II
Posted on March 7, 2014 by weisskoff
Here’s the disturbing part. All of the subterfuge, all of our local adminstration’s efforts to keep us therapists in the dark about deficits in care, has done nothing to obscure the facts. The raw data — the absolute length of time between a first visit and the next visit — is available to everyone who comes to the clinic. An adult who visits our offices today, presenting with depression or panic or post-traumatic stress or bi-polar disorder, will have to wait for, on average, 5 weeks to see the same therapist. There’s no way to hide or spin that fact.
Our defunct committees, the one that ensured we keep pace with changing clinic populations, the one that investigated gaps in how we care for people at risk for suicide, were eliminated for nothing. We now have a clinic devoid of meaningful communication between therapists, administrators, and physicians. And all to keep therapists from discovering new information and reporting it to the State’s regulatory agency. We are failing our patients. It’s obvious prima facie. It doesn’t take Columbo to make the case.
What a waste!
So where do we go from here?
When I started this blog, I thought we would be going to California’s Department of Managed Health Care, to hold Kaiser responsible not just for getting people with mental illness in quickly, but to provide a basic level of service once they arrive. Now I think we need to look above and beyond this watchdog group to their bosses. Who watches the watchdogs? The California State Congress? Maybe we need to go there. And when one considers that a significant portion of funding collected by Kaiser comes from Medicare, Medicaid, and funds from the Affordable Health Care Act, isn’t it time to alert the Feds?
I think it is. And I think we must.
(83 days to go.)
The Billion Dollar Blog
Posted on March 8, 2014 by weisskoff
That’s how much it’s going to cost Kaiser per year to get in compliance with the laws around serving people with mental illness. If we can move these ideas forward successfully, this website may eventually be known as the Billion Dollar Blog. What a soundbite!
It dawned on me this morning that the structure we need to force the system to change is already in place. We just need to apply what we’ve learned from our recent experience challenging illegal initial wait times to challenge substandard follow-up care.
California law states that the members of an HMO must have timely access to mental health care. The focus of our efforts to date has been on the tardiness of the initial visit. We have yet to broach the topic of the care a client receives once they’re in the door. If I meet with someone for an assessment but can’t see them again for six weeks, then Kaiser has provided timely access to substandard care only. Even though Kaiser may be meeting its metric, getting callers in within 10 business days, they are by no means providing what the law demands.
If we want to change the system, and change it quickly, we need to start sending compliance complaints to the agency charged with enforcing these laws. We can make a complaint every time a client needs to be seen by us within weeks but we are unable to book an appointment for months. The DMHC has an email address specifically “For Health Plans and Providers.” They’ve got a mailing address, too.
If I start sending in these reports on my own, I can probably generate at least five this coming week. If everyone in our clinic does it, there will be more like 50-100. If all the therapists throughout Kaiser in California started doing it…! After a week like that, the DMHC will have to take notice.
If they don’t, it’s time to call the Governor.
Such an outpouring of evidence will inevitably have the same effect as the NUHW’s white paper did. Soon after the white paper went public, the DMHC created a plan with Kaiser to get into compliance around initial access. Once the truth about follow-up care goes public, they’ll have to do the same thing to address return access. It could take a year to implement — to hire new staff, rent new office space. But when that year is over our clinics might be providing, finally, appropriate care for the people with mental illness who deserve it.
Where did I get that astonishing billion dollar figure?
We have about twenty therapists on the adult team. It will take twice that many if we’re going to start seeing the people who need individual care at an appropriate level. Let’s say a therapist costs Kaiser approximately $200,000 in salary and benefits a year. Twenty times that is $4 million in our clinic alone. Plus the space to house us. And Santa Rosa has one of the smaller Kaiser medical centers in the Northern California system. There’s San Francisco. There’s Oakland. Then there’s Southern California, Hawaii, Colorado.
Kaiser has the money to finance this change. They’ve been earning over $2 billion in profits for each of the past few years. But they’re not going to be happy about spending it.
(82 days to go.)
On Squeaky Wheels and Reporting Forms
Posted on March 9, 2014 by weisskoff
Below I’m posting an example of a reporting form therapists can send to the Department of Managed Health Care whenever we believe patients need follow-up visits significantly sooner than our next available appointment time. The form can be used after a first visit or a subsequent visit. There are other times when a former client calls me out of the blue, with a relapse in symptoms, and I don’t have an appointment available for six weeks. I can change the form a little to report that gap in resources.
I’m going to start reporting these problems tomorrow and continue for the rest of my time as a therapist at Kaiser. I hope others, colleagues in my department and therapists at other clinics, will join me. Many may be afraid that reporting in this manner will get them fired. I hope to demonstrate that it’s safe to report. I’ll definitely keep you posted.
My goal is to turn the DMHC’s focus from addressing individual client complaints to ensuring an adequate supply of appointments for the entire clinic population. One way the DMHC and Kaiser have been skirting the larger problem is by managing complaints from individual consumers on a case by case basis. When contacted through the consumer reporting line by someone who believes they’re entitled to timely individual appointments, a caseworker from the DMHC calls one of my managers. The manager confirms that the client is not getting the services the laws demand. The manager takes responsibility for remedying the situation. The caseworker follows up some time later with the consumer to make sure everything worked out. Case closed.
When such a complaint is lodged successfully with the DMHC, therapists find ourselves in the position of giving very few clients very special treatment. In a recent case in our clinic, one resourceful self-advocate got weekly therapy (from a manager), and this was promised indefinitely!
This is the squeaky wheel method of patient care. We need to grease all the wheels, not just the squeaky ones.
Here’s my form:
I met with a patient today whose Kaiser medical record number ends with _________. The patient has a diagnosis of _____________________________. I believe that this patient’s psychiatric symptoms will worsen if I do not meet with her/him face to face again within ________ week(s). However, my next available appointment is in ______ weeks.
Though other resources are available to this patient, such as day treatment, skills groups, and urgent appointments with providers other than myself, I believe the basis for resolving this patient’s symptoms is their therapeutic alliance with me. With a gap of _______ weeks, this alliance is damaged, putting the client at risk for further deterioration of their mental health condition.
Denying this patient timely access to their primary therapist is not appropriate care. It is furthermore inconsistent with professionally recognized standards of practice. (See Rule 1300.70(b)(1)(D) that you are designated by the State of California to enforce.)
This report is not part of any union action. It is a sincere attempt to address a system-wide problem with how Kaiser Permanente delivers mental health care. Please follow up with this report in a comprehensive way with our employer so we can deliver the level of service our clients are entitled by law to receive.
Andy Weisskoff, LCSW
CA State License LCS20126
(81 days to change.)
Jerry Can You Hear Me?
Posted on March 10, 2014 by weisskoff
I just sent the following message using Governor Jerry Brown’s website to the staffers handling inquiries about health and human services: http://govnews.ca.gov/gov39mail/mail.php
Hello Jerry Brown,
I’m a psychotherapist who has been working at Kaiser in Santa Rosa for 7.5 years. I’m quitting and blogging my exit at 90daystochange.com.
The mental health services provided by Kaiser, the number one provider of mental health services in the state, are inadequate. In particular the wait times between visits with a Kaiser member’s primary therapist (even if the client is suicidal, even if they’re a veteran of war and have PTSD), currently averages 4 weeks. These wait times are only getting worse with the advent of Kaiser’s participation in Covered California.
Through our union, the NUHW, we’ve been trying to get the Department of Managed Health Care to remedy the situation. We’re going to need the help of the Governor to encourage enforcement of the laws.
Please visit my blog for more details. 90daystochange.com. And feel free to contact me directly.
I have no purpose in pursuing this other than to provide advocacy for people with mental illness who are unable to advocate for themselves.
Thanks for your help!
Andy Weisskoff, LCSW
(80 days to go)
Please, Sir, I Want Some More
Posted on March 11, 2014 by weisskoff
Here’s how it works around our place. We do our best to juggle the daily mix of acute and chronic patients with the staff we have. Periodically, things get out of hand. Our intensive outpatient group might swell to 20 patients, for example, well beyond the capacity of the two therapists assigned to the program to safely treat the participants. Because there is no clinic-wide policy defining an acceptable ratio of staff to patients, and no provision in our union contract, when things get unsafe we are forced to beg our bosses for more staff, or to threaten a union action of some kind.
It would make much more sense to have consistent standards of care. Whenever we fell below these standards, more resources would automatically appear to manage the excess. Kaiser, for obvious reasons, resists creating such standards. As a result, the Department of Managed Health Care, our state regulatory agency, has little to enforce.
This is the biggest impediment to providing mental health care at Kaiser: our lack of clearly defined standards of care.
We need standards created by professionals without conflicts of interest and enforced by the DMHC to enact a reasonable model of care. In the absence of such a model, Kaiser has come up with its own standards, called “best practices,” for each diagnosis we treat. And these practices fall woefully short of treating our clinic population.
Let me describe how these best practices play out in the Santa Rosa Psychiatry Department. If an HMO like Kaiser chooses to cover mental health care at all, (it’s actually a choice), they must provide the same level of treatment for parity mental health diagnoses as they do for other medical diagnoses like diabetes. (See http://www.mhac.org/library/mh_parity.cfm for a good description of parity laws.) Kaiser has a best practice for each of the parity diagnoses. Our best practices for major depression and panic disorder are skills groups.
If you met with a therapist in our clinic in February of this year, your next face to face visit was booked an average of four weeks later. In the interim, if you got a diagnosis of depression, you were probably referred to our 12-week skills group called Mindful Mood Management. The group starts with a one-session introduction. Of the 42 people booked for this introduction in February, 27 showed. Judging by past history, another third will drop out between the intro and the first session. If you were diagnosed with an anxiety disorder in January and agreed to go to our best practices group to address your disorder in February, chances were even worse — about one in three – that you made it to the first session of Anxiety Basics. For the seven plus years I’ve worked at Kaiser, this drop-out rate has been consistent.
Our clinic has an out-of-the-gate failure rate of at least fifty percent for treating the two most prevalent parity diagnoses. And that somehow passes as best practice, the best managed care can do.
Most of my colleagues agree that if we met weekly with clients for the first month of their treatment, we could do a much better job encouraging them to participate in our excellent skills groups. The groups are effective treatments… if we can get our clients to go. But without a therapeutic alliance, without the context for providing encouragement and guidance, our clients consistently drop out.
There’s also a sizable portion of our clinic population that is inappropriate for skills groups. These people get next to no services after their initial assessment. In some cases, I worry we’re doing more harm than good. It’s discouraging to reveal truths to a stranger, perhaps for the first time in one’s life, and then be offered no follow-up care.
We can’t leave it to the HMO itself to generate standards of care. If there is going to be any meaningful change, therapists need an active role and the willingness to promote a new model. When I imagine a better system, I start with four weekly individual sessions. Follow-ups might be monthly, once an alliance is formed, and only when there’s a reasonable expectation that more individual sessions will help. But the starting point must be providing enough time to build the relationship between client and therapist.
The therapists at Kaiser are ready to develop a new model. I wonder when we’ll be invited to the table.
(79 days to go.)
Posted on March 12, 2014 by weisskoff
When I was in sixth grade I had stomach aches, like the boy in Judy Blume’s Then Again, Maybe I Won’t. And I was sad and scared a lot of the time. There were bullies and unrequited loves in my life. There was an angry dad and a depressed mom and a lot of feelings wrapped up in my gut.
My mom saw all this and offered to bring me to a therapist, a guy named Norm Traiger. I met with him once a week for three or four months in his office along the Saugatuck River in Westport, Connecticut. He wanted to know what I was sad and scared about. He told me he had similar experiences when he was my age. He took me with him shopping once, confusing my mother when we passed her in his waiting room, on our way to his car. I ate the Hershey’s kisses he gave me as a gift while he examined sofas at Pier 1.
I told Norm about the bullying and the girls. I told him I wanted to be closer to my dad but didn’t know how to make that happen. He had suggestions for what to do, what to say. I tried the things he suggested. My stomach aches went away. I started sleeping better. I moved on to the next thing, junior high, less afraid and less alone.
The people I see in my office at Kaiser’s Psychiatry Department in Santa Rosa need the same attention I did at eleven. They are living their lives frightened or ashamed or furious. In a very small number of cases, a medicine alone will improve the way they’re experiencing their lives. Everyone else comes to our clinic to meet a person, to use the relationship with that person to feel better about themselves and more content with their lives. This can happen very quickly or it can take some time. But it is the basis of our profession as therapists: to use the relationship to improve the way a client experiences life.
Often clients come to me with very low expectations about what kind of help they’re going to get from managed care. Or they come ready for a fight. They’re used to having to advocate for themselves. They are almost universally suprised and pleased that I am a person, ready to talk with them about what’s wrong. I see the transformation in the first few minutes of meeting. I also have the magic of EMDR. People with deep histories of the most bone chilling abuse come to our department, hoping at best to take just the edge off their crippling anxiety. I tell them instead that they might, through therapy, and at Kaiser, find a route to some peace of mind.
And I’m just regular. My colleagues have the same ambition for their clients, and the same sense that the route to better emotional health is through the relationship. We have different styles and levels of engagement with our clients. But we all know a person needs to trust us first before they’ll believe anything we say and dare to make positive changes.
Over the seven years I’ve been at Kaiser, I’ve watched the time we’ve been given to form and use this relationship leach away. I tell my disappointed clients that we’ve been fighting, tooth and nail, for every hour. Left to its own devices the inertia of managed care will whittle this time to none.
We all have to speak up. Mental health practitioners and consumers must gather our momentum and defend this time as valuable. We need the time to build relationships and make change possible.
We mustn’t let it go.
(78 days to go.)
Front Door, Back Door
Posted on March 13, 2014 by weisskoff
Imagine that any mental health clinic has a front door and a back door. The doorman checks to see if you’re in the right building, then lets you in. There’s a back door, too, of course. Without it, the room would fill and fill and fill until someone has to call the fire marshall.
After being fined $4 million in June 2013 (a fine they are still contesting in administrative court), Kaiser was forced to (1) allow anyone in the door who might be appropriate for mental health services and (2) to do this in the time frame explicitly spelled out in the laws governing HMO behavior in California. (See http://healthconsumer.org/cs016knoxkeene.pdf for a good summary of these laws.)
With the help of our union, the NUHW, and as a result of these fines, the Kaiser Santa Rosa Clinic has changed the guard at our front door. Before the fines, phone triage therapists were more like bouncers, the kind who only let you in if they like your looks. Now they’re more like greeters at Home Depot.
Opening the front door meant hiring more therapists to meet with these new clients, the ones previously being discouraged from entering. Before the fines, we were either putting people on waitlists or recommending they look outside Kaiser for what they really needed — invidividual therapy. When we changed up, in our clinic alone, Kaiser was forced to purchase five new therapists to meet the increased demand. By my very loose reckoning, it cost them about a million dollars a year to meet the new demand.
But now we have a new problem in our clinic: overcrowding. To address this problem, Kaiser has torn down the entire back wall, metaphorically speaking, to allow sufficient egress for all these new patients. If they hadn’t done that, then like the house in Alice in Wonderland, we would have exploded. What Kaiser actually did was eliminate some of the therapists’ return appointment slots and create new slots for initial visits. More intakes, fewer returns. In our first ever face-to-face confrontation with our bosses a year ago, therapists in our clinic soulfully raged against this transfer of resources.
But you need more than soul to influence the managed care machine.
If we want to have a fully functional clinic that actually serves our clients, one that doesn’t just bring them in the front door and escort them out the back, we need to guard the back door. That’s where the bouncers need to be. (“You will not leave. You will stay and dance, dance, dance, until your spirit has been restored!”)
In managed mental health care our back door guard is made up of the laws governing appropriate treatment of people with mental illness. As I’ve said here before, because these laws are vague, what constitutes care can be, and has been, argued down to next to nothing in terms of one-on-one time.
Managed care as a rule provides only what the law requires. Which clarifies what must be done. We need to rewrite the laws governing minimal care and hold the Department of Managed Care accountable for enforcing them. To do this we need to mobilize the forces that got these laws, including Parity Laws, written in the first place.
I’ve started contacting consumer groups to move this effort forward. I called the National Alliance for the Mentally Ill (NAMI), both our local chapter and the state chapter, to get the ball rolling. Anyone reading this blog, and there are about 500 of you so far a day, it’s time to get the word out to consumers. This is the next step.
Change the laws so we can keep those in need from being hustled out the back door.
(77 days to go.)
This Joint is Jumpin’
Posted on March 14, 2014 by weisskoff
On Monday, Tuesday, and Wednesday this week I emailed one report a day to the DMHC address designated “For Health Plans and Providers.” The reports were about clients I had just seen who I wouldn’t get to see again for at least six weeks. On the day I saw them my next availabe return slot was in six weeks. I thought these three clients should be seen within two weeks.
The website that describes the ways clients and providers can report misconduct to the DMHC is: http://www.dmhc.ca.gov/aboutthedmhc/gen/gen_contactus.aspx.
On Wednesday, I got a call from someone in Kaiser Human Resources who wanted to talk with me about my “concerns.” This was the same person who last year investigated a complaint we therapists lodged about retaliation. At that time, some of the physicians had gotten upset that we were reporting unethical and illegal conduct directly to the DMHC. They let us know they blamed us for turning the clinic topsy-turvey to meet access laws. That retaliation investigation led to no discernible action. I wrote the investigator back and said, politely I hope, “No, thanks.”
On the same day, Wednesday, my buddy at the NUHW let me know that an investigator with the DMHC wanted to speak with me about the reporting forms I was submitting.
Thursday was kind of quiet, except for a blowout with my son over his grades.
Today, Friday, my direct supervisor invited me into his office. He asked if there was anything he could do to address, again, my “concerns.” He asked if it was OK if I stop getting assigned new clients starting in April rather than May so I could have enough time with the clients already on my caseload. He asked if it was OK with me if I do less phone triage so I could have even more time for return visits. He wanted to know if I would like to increase my work hours from 36-40 a week to have even more time.
He had been ordered, I think, to put out my fire. If I’m given all the time I could possibly use to see clients already on my caseload during my last (76) days, then I shouldn’t have anything to complain about to the DMHC. At least I think that’s what he was trying to do. Don’t you?
Giving me more return time defuses the arguments about my clients receiving substandard individual care. But what about everybody else’s clients? And what about all the clients I’ve had over the years who didn’t get to see me in a timely fashion and struggled unnecessarily as a result? I’m still on fire about all those guys.
I’ll be talking with the DMHC investigator on Sunday about how to gather the data they need to hold Kaiser accountable for providing adequate one-on-one time. I’ll let you know what I find out. Because once that’s clarified, it’s time to step up, therapist by therapist, and report what’s going wrong.
So our clients can get what’s right.
(76 days to go.)
Kaiser Docs for Change
Posted on March 15, 2014 by weisskoff
In my first four years working for Kaiser in Santa Rosa, Bob Schultz was the Physician-in-Chief (PIC) of the Medical Center. He was the kind of guy you’d want as your family doctor – soft-spoken, gentle, wise, sure of himself and his mission as a healer. He came to the Psychiatry Department periodically to deliver motivational messages to all the staff – MDs and everybody else.
I remember the last message he delivered before retiring: Kaiser Santa Rosa Medical Center will be voted the best medical center in the United States within the next three years. He spread his arms wide and said, “It’s not like we’re this far from that goal.” Then he brought his palms within inches of each other and said, “We’re this far.”
On the same day he delivered his “we can be the best” message, he was accompanied by the PIC-to-be, who became our leader in May 2011. The PIC-to-be had a very different message. Paraphrasing from my memory of the stunning event, he said, “Here’s what I tell my physician colleagues, when they tell me they don’t like the deal here at Kaiser. I tell them, ‘Check it out. Look around. If you can find something better, take it.’”
Message 1 — Kaiser, Santa Rosa: We’re this close to being the best in the country!
Message 2 — Kaiser, Santa Rosa: If you don’t like it, leave!
It’s not that much of a leap from, “If you don’t like it, leave,” to, “If you don’t like it, and make a stink about it, you’re outta’ here.” I know of at least one MD, not from Santa Rosa, recently fired for going against the company line. My buddies at the NUHW told me last month that they had received a phone call from a physican who had been protesting unethical care in her department and was canned. She had called the NUHW just to let them know she supported our efforts to improve patient care. She also wanted to know if there was anything they could do to help her get her job back.
The physicians who own the Kaiser Permanente Medical Group don’t seem to have a clear pathway to participate in the decisions their company makes, even though they own the company. It seems more like the company’s executive officers are making the decisions about the health care we all provide. In 2012, according to the LA Times, the former CEO of Kaiser George Halvorson (not a doctor) earned $7.7 million to direct the choices that eventually filter down to our clinic’s level, including how much therapists, nurses, nursing assistants, receptionists, and security guards earn. And which services we provide and which we cannot.
My friends who are Kaiser doctors say they would speak up and make changes if they felt free to do so without reprisals. Some even say they’d be willing to earn less money in order to have better care for their patients and a more reasonable workload for themselves. I wonder how many this is true for. Maybe one in ten? Or one in four? It’s quite an effective system that can silence the voices of so many of their rank and file.
It makes me wonder if the real stumbling block to providing adequate mental health care to Kaiser members isn’t the lack of clarity in the legal code, but the power of the health care industry to block enforcement of any laws. It has enough money to influence every branch and level of government including the Department of Managed Health Care. Unless the doctors who own the Kaiser Permanente Medical Group instruct their leaders to prioritize care over profit, the system won’t change.
Just in case the physician owners of Kaiser are willing, but need to develop a voice for change, I checked. And as of today, kaiserdocsforchange.com is available for purchase. On sale for $9.99.
(75 days to go.)
Testing. Testing. A Reasonable Model of Care. Testing. Testing.
Posted on March 16, 2014 by weisskoff
It dawned upon me during my walk through the redwoods just now that all the pieces are in place for moving forward with a new and improved system of managed mental health care at Kaiser. We just need to put one foot in front of the other.
Over the last three years, and thanks to the sustained efforts of the National Union of Health Care Workers (NUHW) collaborating with the Department of Mental Health Care (DMHC), we now have the structures in place to promote dramatic change. As a result of the NUHW’s challenge to delayed initial access to care, a system was created by the DMHC and Kaiser for easy auditing. The DMHC also backed up these audits with fines for non-compliance.
This system was immediately effective. Once Kaiser was fined $4 million, five therapists were hired in Santa Rosa and many therapists were hired in clinics throughout California. With the easy auditing system, the DMHC knows that Santa Rosa was in compliance with the laws up until the first of this year. They also know, because of the advent of Medi-Cal patients and Covered California patients, that we’re slipping out of compliance. My bosses are scrambling to keep up to avoid future fines.
The next step is to define minimal but adequate mental health care for the clients coming through our now wide open doors. I say “minimal” because that’s how managed care operates in all areas. Mental health will be no exception. We must define a minimal standard of care and then the DMHC will be responsible for enforcing that standard.
Here’s my proposal for minimal but adequate care for any client who meets medical necessity. Medical necessity means that the client has a condition that the managed care system has legally obliged itself to treat. In mental health care these conditions include at least the parity diagnoses.
(A) For new clients (people who have not been seen by a therapist in our clinic in over a year): the capacity to see the same therapist in the same time slot for 4 consecutive weeks. That therapist becomes their primary therapist, analogous to a primary care physician.
(B) For follow-up visits (any visit after the first four, including for clients who call in after a break in treatment needing help): the capacity to meet with their primary therapist within two weeks.
We’ll need to establish a minimal standard, either mine or someone else’s. The therapists already doing the work within managed care are the experts on this, so it seems reasonable that we should be the ones to set the standard.Mine sounds good to me and my colleagues, but maybe it doesn’t sound adequate for therapists at other Kaiser clinics. It might actually be underambitious. (I wouldn’t be surprised, considering the crumbs we’re all used to.)
An exciting aspect of the two-part proposal above is that it can be monitored easily by the DMHC, just like the initial access metrics can be monitored. Auditors can check the three metrics at the same time: (1) initial access, (2) availability of 4 consecutive sessions to start, and (3) availability of additional sessions within two weeks. If the DMHC gets on board with this being a minimal standard of care, and we present an easy strategy for auditing, then there will be but one issue. But it’s a biggie. Is the DMHC free enough from Kaiser to do their job?
This will certainly be the test.
(74 days to go.)
The Damage Done
Posted on March 17, 2014 by weisskoff
I left last night’s phone chat with an investigator from the Department of Managed Health Care (DMHC) a little deflated. The person I spoke with was very clear that he or she did not want to be identified in this blog. So I won’t identify him or her.
Of interest to the investigator was any evidence I had of patients who had suffered damage as a result of delayed access to a first or subsequent visit. I told the investigator my anecdotes — two suicides and a murder that I suspect could have been prevented if we had shorter wait times between appointments.
But even as I told these stories I realized what we’re up against, the old maxim from statistics that correlation is not causation. Meaning: just because we have long wait times, and our clients have bad outcomes during those wait times, doesn’t mean that the waits are causing the bad outcomes.
If we keep the discussion focused on bad outcomes, the DMHC (in its role representing the clients of an HMO) is going to get nowhere. Kaiser can easily make the argument that assessment and referral is just as good as weekly therapy, so they’re justified in following the cheaper path.
Would the DMHC be trying to make this argument in physical medicine? If you go in to your doctor with a broken ankle, your visit is a success if the ankle is repaired, right? Not if you don’t die. The same should be true in mental health. Much more than preventing bad outcomes, we are facilitating good ones. Decreased emotional suffering and improved functioning at work, home, and in relationships, are our general goals as therapists. We do that by building a therapeutic alliance and then offering suggestions, teaching new strategies, reviewing the wisdom of alternatives to the roads our clients are used to taking.
How do we prove the presence and value of those positive outcomes that can only come during one-on-one sessions? How can we turn the DMHC to advocate for growth, since arguing for the prevention of bad outcomes seems to be the garden path?
When your broken ankle is repaired, there’s physical evidence, scans, for example, that show the repair was complete. With mental illness, the evidence is the subjective report of our clients. They feel better. They experience their lives as going in the right direction. Their relationships improve.
Instead of looking for evidence of damage done when our clients don’t get to see us, the DMHC should be asking for proof of our successes when they do.
(73 days to go.)
The Voice of the People
Posted on March 18, 2014 by weisskoff
I just sent this message to Marta Green, Deputy Director of Communications and Planning at the Department of Managed Health Care in Sacramento.
Pleased to meet you! I got your name from one of your investigators who said you would be the right person to contact about general matters of DMHC operations. As you may know, I’m a therapist working in Kaiser Santa Rosa’s psychiatry department. I’m blogging my exit at 90daystochange.com. I believe Kaiser is systematically eliminating all individual therapy hours at all of its sites, the ones, that is, that still offer any return times at all.
As part of my effort to stop this reduction in services I would like to develop a strategy for assembling the voices of the consumers who do not wish to lose this essential portion of their benefit. In our clinic I’ve been directing clients to the DMHC contact info consumer reporting line 1- 888- 466-2219. I wonder if you’d be willing to set up a separate phone tree option for Kaiser mental health clients. Or, if possible, to set up an entirely different line for the time period between now and the May hearing in Oakland. I hope to give you, the consumer protection advocates for HMOs in California, the fuel you need to keep fighting the good fight for our clients. If the hearing is cancelled, if Kaiser withdraws its protest of the $4 million fine, then you will still have the data you need to enforce the laws around providing adequate mental health care.
I’ve been blogging for only 2 weeks, yet have a readership of 850 individuals. These are mostly therapists and bosses of therapists, I suspect. But more and more consumers are discovering the site. There’s an editorial in our local independent newspaper that’s about to come out, directing a new batch of consumers to the website. And I plan on writing an editorial piece for the LA Times and one for the NY Times this week.
This is extraordinarily important information to collect. If I don’t hear from you, I’ll assume the 466 number is adequate. Feel free to contact me directly.
Andy Weisskoff, LCSW
(72 days to go.)
Take the Money and Run!
Posted on March 19, 2014 by weisskoff
In Sonoma County, home to Kaiser’s Santa Rosa Medical Center, most people with mental illness who are low income have historically been served by the Behavioral Health Division of the County’s Department of Health Services. The County runs a 24-hour psychiatric emergency service and a variety of programs, specific to sub-populations like the elderly or people involved in the criminal justice system. The majority of these programs are run on MediCal dollars, MediCal being the California version of Medicaid, the Federal/State medical insurance program for families, the elderly, and disabled individuals with low incomes.
At Kaiser in Santa Rosa, mental health services for MediCal patients have been, up to this point, outsourced to the County. That means that Kaiser MediCal patients who have their bodies healed by Kaiser go to the County for mental health services, not to our Psychiatry Department. This artificial split (Kaiser fixes the body, the County fixes the mind) has always been an impediment to quality integrated care for these clients.
The therapists in the Psychiatry Department first got wind of big changes around Thanksgiving last year. We were told that some of the clients who were previously carved out to the County were about to be carved back in as part of the “Partnership.” And that was all the information we got.
How many people were coming? What services were they going to need? What was the plan to serve this new population? Our bosses shrugged their shoulders and said, “That’s all we know right now.”
Just before the new year, the therapists working the triage phones were told that come January 1, we were going to start accepting some of the patients previously seen by the County — only those who were already receiving medical services at Kaiser, and only those without serious and persistent mental illness (SPMI). The first part would be verified by our front desk receptionists, who receive initial calls and transfer them to the triage therapists. The second part, how to distinguish between SPMI and not SPMI, was left vague. Possible factors to consider were diagnosis, length of illness, history of hospitalization, gravity of symptoms. But we were given no additional guidance. “Do the best you can,” we were told.
On January 2, we started doing the best we could, and these Partnership people started pouring in.
As a rule, the less income, the more need. This axiom was taught at the School of Social Welfare at UC-Berkeley when I went there for my MSW, and it always bears out. Even though triage therapists had been instructed to “cream” the easiest of the County clients, the people we let through still needed more services than the average client already in the system — another reason our return appointments have disasppeared.
The Partnership people are also flooding the Emergency Department, and with different needs than the clients we had been treating there prior. This past weekend, on Friday, Saturday and Sunday, my colleagues who worked on-call assessing clients for hospitalization, reported much longer than usual shifts — 25-50% longer.
I used to work for the County in an Assertive Community Treatment (ACT) model program that served MediCal clients caught up in the legal system. The case management model developed for this population had a ratio of 20:1, twenty clients to one case manager. Case loads closed at twenty. Not that the new clients we are seeing have the same level of complexity as those in the ACT program I used to work with. But they clearly have more need than we’re used to. And, apparently, there are no plans to assess these needs or develop a model to serve this population.
In short, Kaiser started pocketing money on this specific population of very needy people starting January 1, without putting a dollar into planning for or providing the resources to serve them.
I’ve stayed calm to this point. But as you might have surmised, this really pisses me off.
(71 days to go.)
Tough All Over
Posted on March 20, 2014 by weisskoff
One of the privileges of being a steward for the National Union of Healthcare Workers is going to the steward’s council meeting once a month in Emeryville. You get the skinny on everything going on everywhere else in Northern, CA.
In Oakland, therapists are poised to walk out. In addition to eliminating functional programs that were serving a variety of target populations, Kaiser Oakland recently instituted cluster intakes. Here’s how they work. A bunch of therapists are scheduled to be available at the same time. Then Kaiser overbooks clients, assuming that some won’t show up. When the clinic gets unlucky, when more clients than therapists walk through the door, some of the therapists are forced to stuff two intakes into the time slot for one. Needless to say, when this happens it’s stressful for therapist and client alike. This seems to be the straw that broke the camel’s back in Oakland, since the therapists are ready to strike. Watch the news and listen to NPR for updates on this one.
I’ll just give you one more fact I learned at the steward’s meeting that made me sink even deeper in my seat. In just the past two months, the Santa Rosa Medical Center — from Covered California, Medi-Cal and the opening of a local casino — has added 5400 members. That’s a gain of 3.7% in the last two months alone. And no guidance from our management about how they (we) are to absorb the subset of this population who are seeking mental health services.
Yesterday I spoke with a colleague who moved a year ago to a Los Angeles Kaiser. I was not surprised but still disheartened to hear that the wait times in LA to see therapists for follow-ups are the same as ours. And their bosses have the same apathy and silence about the impact on clients.
At least Kaiser management is consistent. It means a consistent strategy to address their negligence will impact the whole system.
To this end, I put up a link on this website for consumers (clients of the Kaiser’s mental health system) to report directly to the Department of Managed Health Care (DMHC). I did this after receiving a return e-mail from Marta Green at the DMHC. She wrote: “I really appreciate you sending potentially affected consumers to our Help Center line and helping to spread the word that we can be a resource to folks who are struggling to get the care they are entitled to.” AND: “Every consumer you send our way is helpful for this case, as well as any other issues folks may be facing when getting care.”
OK, Marta, hold on to your socks. Because here they come.
(70 days to go.)
Phone Lines are Open, Marta’s Standing By
Posted on March 21, 2014 by weisskoff
I sent this today by email to all staff of the Kaiser Santa Rosa Psychiatry Department. (You’d think they would have disabled my group mailing list function by now. I wonder if I can send to the whole medical center.)
I’ve set up a consumer complaint button on the website 90daystochange.com. The button links to a page which describes how our patients can call the Department of Managed Health Care (DMHC) and lodge a complaint about our services.
I set this up after communicating with Marta Green, a Communications and Planning Director with the DMHC. She wanted me to know: “I really appreciate you sending potentially affected consumers to our Help Center line and helping to spread the word that we can be a resource to folks who are struggling to get the care they are entitled to.”
Anyone who has contact with our patients, receptionists, nurses, nursing assistants, physicians, therapists, anyone has the right to pass on the name of the website 90daystochange.com and the phone number for the DMHC. The website was developed exclusively to improve the care of our patients.
The phone number for the consumer reporting line is: 1-888-466-2219
The website, in which our patients are encouraged to exercise their rights, is:
The Kaiser Santa Rosa Medical Center grew by 5400 members in the first two months of 2014, a gain of 3.7%, which explains why we’re suddenly so overloaded. Getting our customers to speak up is the best chance we have to change the situation around to their benefit.
Be brave, all!
As long as we keep our focus on protecting our clients, we are on the side of right. If you are instructed to keep this information about reporting to the DMHC from our patients, please speak with your union representative, as I believe your rights, and our patient’s rights, would be violated through that withholding.
(69 days to go.)
Get Up , Stand Up
Posted on March 22, 2014 by weisskoff
I sent this email to the Department of Managed Health Care (DMHC) investigator I spoke with on March 16. The one who shall not be named in this blog. The one who may or may not be working on the legal case to be heard before an administrative judge in May. The case in which Kaiser is attempting to beat the $4 million they were fined for denying timely access to care for mental health clients. I wrote…
I found on page ten of the “Final Report, Routine Medical Survey of Kaiser Foundation Health Plan, Inc Behavioral Health Services, Issued to Public File on March 18, 2013,” under “Implications”:
“If the plan does not effectively monitor wait times and ensure that enrollees are not waiting excessively for an initial appointment or between appointments with their provider, significant numbers of enrollees with untreated or prolonged health conditions may suffer harm.” [emphasis added]
Despite the changes to initial access, there are at least three ways in which our enrollees, clients of the Psychiatry Department at Kaiser Santa Rosa, are still waiting excessively between appointments. As a result, significant numbers are suffering harm. There are simple remedies to these problems which I’ll offer here. If there were no structural solutions, I might as well be shaking my fist at the gods. But there are solutions. They’re just going to cost the health plan money.
Our bosses these days are, understandably, focused on avoiding further initial access fines. At the same time, they don’t want to spend more money than necessary to beat these fines. We are staffed just enough to have new therapy appointments available within two weeks for everyone who requests one.
When a new client calls in, we triage therapists (I do this work twice a week) have two choices — either book an urgent appointment (within 2 days) or book a non-urgent appointment, usually very close to the two week target. That’s your choice, two days or two weeks.
We know what happens to the client booked with a non-urgent appointment. Their next visit with the same therapist is in four weeks. For clients booked an urgent appointment, the result is even more chaotic.
The therapist who sees a client for an urgent appointment primarily assesses for dangerousness to self or others and sets up acute care follow-up — sometimes in our Intensive Outpatient Program, sometimes in another of our groups serving people in crisis. The urgent care therapist also usually sets up an appointment with another therapist, typically someone who will take on the role of primary therapist. The soonest available time for this second face-to-face appointment is the same two weeks as a non-urgent initial appointment. And then that therapist, the primary therapist, won’t be able to see the client again for another four weeks.
During the first gap of two weeks, between the urgent visit and the one with the new primary therapist, there’s often the need for more urgent appointments with other clinicians unfamiliar to the client. During the next gap of four weeks, between visits with their primary therapist, the client often requires help stabilizing. There can be even more urgent visits with other therapists.
As you can see, the system treats each visit as a discrete event instead of addressing the client’s continuous need for help. Our clients frequently don’t land with a therapist they know and trust for months. This system is unnecessarily stressful to all involved.
I see a two-part structural fix for this problem. If all therapists had an equal number of urgent appointment slots and non-urgent ones, and therapists “kept” both sets of clients, urgent and less urgent, then the clients most in need would have immediate and continuous care with a primary therapist. The primary therapist, however, still would need time to build the alliance crucial for effective treatment. So we should also offer every new client several weekly sessions in a row. This happens to be the minimal standard of care in the community.
One of our primary strategies for managing large caseloads is referral to skills groups. But only half of the people diagnosed with depression or anxiety and referred to the related best practices groups show up for the first session. Of those, if we’re lucky, another half will continue until the end of the group.
The fix for this problem is the same one mentioned above — initial weekly sessions with the primary therapist. When we meet with clients a few times in a row, they trust us enough, and we can encourage them enough, to follow up with group treatment. Without this support, most clients simply drop out.
This problem is brand new. It’s only been going on since January 1, 2014. I thought it was a local phenomenon, but it seems to be more widespread. MediCal clients previously being treated by counties, in our case Sonoma County Mental Health, are getting adopted selectively into Kaiser’s Psychiatry Departments. The selection criteria are vague and confusing. We’re supposed to take in only the people who don’t use expensive services, like crisis residential treatment or psychiatric hospitalization. But sometimes our predictions are off.
The lack of clarity is hard enough on providers and clients as they self-refer. But I learned in the past week that when we err, when a client we thought was cheap turns out to be costly, the client gets returned to the County. There’s a form our bosses fill out to enable the transfer. I know of at least one case where this has already happened. I’m sure it’s not the only one.
These are the most fragile people in our community – low income, mentally ill – and they’re being bounced around at the whim of the bean counters. The solution here is to define more clearly who we are adopting, and then to keep those adopted clients for some designated period, perhaps a year, before considering a transfer. (It’s actually more like a foster system than an adoption. Kaiser gets paid to care for them.)
I hope I’ve made it clear, unnamed investigator for the DMHC, that I am happy to testify in court regarding the systemic and ongoing mistreatment of our clients. They deserve better than this and I’m proud to stand up and say so.
(68 days to go.)
Start the Presses
Posted on March 23, 2014 by weisskoff
It’s a beautiful Sunday. I haven’t wanted to do much writing, so the trade-off was to go for a brief act of bravado.
I adapted my first blog entry and emailed it to the editorial departments of the Press Democrat (the Santa Rosa newspaper) and the San Francisco Chronicle. I hope someone picks it up. If not, I’m going to try a longer piece for the LA Times or New York Times. For any faithful readers of this blog, most of this will be a rerun:
I’ve been a psychotherapist at Santa Rosa Kaiser’s Psychiatry Department for more than seven years. Throughout, it’s been a struggle to provide the kind of therapy I’m designed by training and constitution to practice — the trauma treatment called EMDR. In the last few months the obstacles have become insurmountable. And now it’s time to leave. At the end of February I gave three months notice. It will take that long to safely finish the work I started with the people already on my caseload. EMDR, like most effective therapies, is dependent on the relationship between client and therapist. No one else can finish this work for me.
Quitting Kaiser is not easy. Last year, in 2013, I grossed $107K, a social worker salary unparalleled in Sonoma County. Private practice will not yield that kind of money. And I feel very guilty about leaving my fellow therapists and clients behind. Three months ago I took on a leadership role in the clinic by volunteering to be a shop steward. Now I’m abandoning ship.
Why am I giving up after only three months of stewarding? Why am I turning in my resignation?
With the addition of Covered California and MediCal patients, and with no additional resources for their treatment, the average wait time between therapist appointments is now four weeks. Four weeks! Therapists cannot provide meaningful care in this context. I’ve thought about surrendering, doing only what long wait times between appointments allows — assessment and referral to one of our groups. But if I surrendered, there would be no more of the work I love to do best, the work my severely traumatized clients truly benefit from.
Instead, I’m quitting. But as I go I’ve decided to get busy advocating for a comprehensive shift in the delivery of mental health care within managed care. I’m speaking up in any forum I can tap into, starting from within the clinic, but on up to the Department of Managed Health Care where the real power for change resides. The DMHC is the state’s watchdog agency that a year ago handed Kaiser a $4 million fine for not providing timely access to care. There’s an administrative hearing in Oakland in May, in which Kaiser and the DMHC will face off. Kaiser is attempting to beat the $4 million in fines, claiming that despite the near-absence of individual therapy time, they are providing adequate care to our clients.
I’ve set up a website, 90daystochange.com, to help Kaiser members with mental health needs get the care they deserve. Kaiser is the number one provider of mental health services in California. Yet it is woefully behind community accepted standards of care, starting with the availability of a primary therapist. My hope is to have as many of our underserved clients as possible contact the DMHC directly, and right away, so they’ll have plenty of fuel in court in May.
To go up against the largest HMO in the United States, they’re going to need it.
(67 days to go.)
Don’t Go Jerkin’ My Chain
Posted on March 24, 2014 by weisskoff
I sent this out via email to the Kaiser Santa Rosa Psychiatry Department adult team. That’s everyone except for the child and family team clinicians and the chemical dependency team clinicians. I missed an impromptu brainstorming session last week because I was at the union meeting in Emeryville. But I heard that our boss had opened the conversation up to considering new strategies for improving our between-visit access times. I find this very promising.
Hi Adult Team –
I was accused recently by one of my MD colleagues of “jerking the chain” of my bosses in the email I sent everyone on Friday. That email was about creating the kind of leverage system-wide, state-wide, to facilitate broad improvements for our patients. This one is about how to regroup and rebuild in this clinic. Hopefully, it won’t be seen as jerking anyone’s chain.
I understand that there is some interest in an adult team off-site in order to address the range of problems we’re currently experiencing. I think this is an excellent idea. It would be most effective if we had the participation of MDs, therapists, nurses, nursing assistants and perhaps receptionists — all the players necessary to ensure a smoothly flowing clinic.
A good starting place might be addressing our lack of team-wide goals, including a coherent mission statement for the department. Many of us would be happy to rally around a cause, but it needs to be something more inspirational and less cynical than, as examples, “Our mission is to avoid more fines,” or, “Our mission is to impress the $12K, once a year, visitor in order to keep his business.” How about: “Our mission is to alleviate and prevent the symptoms of mental illness among our members by offering a wide range of cost-effective strategies”? To get on the same page on at least our collective purpose might prepare us for the more challenging tasks we still need to address.
But I wouldn’t want to spend all day on a mission statement.
There are a series of crucial objectives not being met that an off-site would help us clarify and operationalize. I’ll give a few examples of critical goals my colleagues and I have for our clinic, and the problems generated by not having team-wide agreement about their significance.
Goal: To quickly and thoroughly establish new patients with one clinician who will serve as their primary mental health care provider, equivalent to a PCP.
Problems that arise when we don’t structure around this goal: Patients bounce around from clinician to clinician in the first critical weeks and months of care. As a result many deteriorate further and require higher levels of care or get discouraged and drop out of treatment.
Goal: To promote skills and insight over medications whenever possible.
Problems that arise when we don’t structure around this goal: (1) Patients who see medications as their sole psychiatric resource stay forever on psychiatrist caseloads. (2) Patients who only use medications to address their symptoms are much less likely to improve than those using a variety of strategies.
Goal: To improve the quality of patient care across systems and providers.
Problems that arise when we don’t structure around this goal: (1) Flaws in the system that lead to adverse outcomes (like suicides and hospitalizations) that could be addressed remain in place, paving the way for more adverse outcomes. (2) Issues that could decrease suffering and improve the quality of life for future patients go unexplored. (3) As a result of 1 and 2, clinicians develop a detachment from their work, a learned helplessness, otherwise known as burnout. Needless to say, clinician burnout affects patient care dramatically.
I’m hoping that enough of you share these goals so we can consider addressing them in a meaningful forum. In any case, let’s keep the conversation going across disciplines.
These patients belong to all of us.
(66 days to go.)
Free at Last
Posted on March 25, 2014 by weisskoff
I was getting kind of depressed this past weekend. Sometimes I put the pieces together and come out with optimism. The Kaiser mental health system will undoubtedly change, I think in these moments. At other times, certain truths pop out that make me less hopeful.
For example, a week or so ago I was sure that the best way to improve services was to clarify the legal codes that the Department of Managed Health Care (DMHC) enforces. But a short conversation with my buddy at the National Union of Healthcare Workers (NUHW) ended that line of thinking. Fred said, “If you try to change the law, all the lobbies that have an interest in keeping things vague will come out of the woodwork and shoot it down.” Which, of course, made sense. It’s why the laws were left vague in the first place. They were as precise as the politics of the time allowed. And have things changed enough since the laws were written, in terms of public interest in mental healthcare, to overpower Big Money? This weekend I worried no.
On down the rabbit hole I went, wondering next if the DMHC has the authority to demand care beyond what the deliberately vague laws suggest. On what basis will they build arguments that Kaiser needs to provide a basic level of service, or improve their continuity of care, or set up authentic quality assurance systems? Can the DMHC afford, politically, to listen to what therapists and clients have to say on the matter, to synthesize this material and come up with new policy?
But today is my wife’s birthday. A reminder that everything changes. Not only is it her birthday, but last week she finished a memoir she’s been working on for, oh, fifteen years or so. (Just wait until you read it!) And in a little over two months I’ll be leaving Kaiser and starting a whole new chapter in my career too. Our lives are changing dramatically.
Thinking about these personal changes this morning reminded me of all the systemic change that has already come about in the last three years — since the NUHW started organizing therapists to address deficiencies in the treatment we provide. The pressure from consumers and clinicians isn’t dissipating. It’s growing. Ongoing pressure in the face of ongoing problems means that improvements will continue until these problems resolve.
And then I checked my emails. There I got word of the first comment from a mental health client who has something to say on this blog about the treatment she’s received at Kaiser. Have a look. It’s under the Andy Weisskoff, LCSW tab. As you can imagine, this made my day. It meant that (1) somehow consumers are finding out about this blog, and (2) somehow they’re getting up the nerve to speak up, even in this public forum.
Three years ago, though therapists were risking our jobs, we began blowing Kaiser’s cover about mental health services. And now mental health consumers, a disenfranchised group if there ever was one, people who have reason to worry that if they complain they’ll be denied the meager services they’re getting, are risking the little they have for a chance at getting enough.
You hear that, Kaiser? Repression has its limits.
(66 days to change.)
Posted on March 26, 2014 by weisskoff
I don’t know why I thought things would be different in Southern California. They’re not. I spoke with a Kaiser therapist today who, as part of her job, interfaces with mental health clinics from Modesto to San Diego. Wait times between therapist appointments are the same four weeks average, in all these clinics, as in Northern California. As a responsible discharge planner, she’s been making recommendations about care for these acute needs clients, including sometimes individual sessions as often as once a week. Tracking what actually happens to these folks has been so disheartening that, after many years at Kaiser, she’s lined up her next job.
I also got word today that Oakland therapists have voted to walk out unless there are immediate staffing improvements. That’s going to be a national news story in a minimum of ten days, since that’s the amount of time NUHW therapists must give our employers before we strike. Oakland has a huge clinic and is also the home of Kaiser’s corporate headquarters. It’ll be a big media event.
In our clinic in Santa Rosa, each day feels more chaotic. Clients who aren’t getting timely follow-ups are falling apart. Our management, bogged down in individual customer complaints, is so lost in dousing flames they can’t see the forest on fire. Without the stabilizing influence of primary therapists and the time to meet clients face to face everything comes loose.
The conclusion from all of this chaos in the midst of plenty is inescapable.
Kaiser has sucked up these huge new pools of customers, statewide, without intending to provide them with help for as long as they can get away with it. Covered California. MediCal. They’ve done this despite profits of over $2 billion a year for each of the last five years. I guess it’s not “despite profits.” This must be how they make profits. They’ve taken a calculated risk that in the confusion around implementing the Affordable Care Act, they’ll be forgiven some poor planning. But this is not poor planning. These are some very smart, very deliberate business folks. They’re not going to enter a new market without a cool guarantee of profit.
Is it exciting that Oakland therapists are going on strike, and that the rest of California’s therapists will surely follow? Absolutely. But will strikes on their own solve the problems? Probably not. Our work stoppages, reports to the DMHC, broadcasts of conflicts of interest at the highest levels of the corportation, class actions suits on behalf of clients. They’re all just part of the equation.
Kaiser knows the range of what therapists and consumers can do. And they’ve got the cash to wait us out.
At least that’s their plan, anyway.
(64 days to go.)
R and R
Posted on March 27, 2014 by weisskoff
It’s akin to dying, leaving a job. There’s a succession of detachments. The last time I’ll stand in front of a group and teach mindfulness. The last time I’ll go to the hospital in the middle of the night for an on-call shift. I’m already rummaging through my desk discarding files I haven’t touched in five years. I started this blog in anticipation of this process, knowing that once I’m done with Kaiser, these issues that seem all-encompassing while I’m here will be out of sight out of mind. Replaced by the next thing.
I don’t know if you can tell from yesterday’s post, but I can see that this process of detachment is being hastened by escalating conflict. In our clinic, every day, there are new confrontations about changing policies that affect client care. In conversation with therapists up and down the coast, I’m hearing a uniform theme. Deliberate and calculated negligence and power grabs. What got me most yesterday was the local aspect. Friends and colleagues, who have worked together for over a decade, are turning against each other in the melee, instead of challenging the dysfunctional structures that serve the profit motive but not our people.
I try to practice what I preach. The overarching framework I encourage my clients to adopt is straight out of the 12-step world. The serenity prayer, paraphrased to: identify the things in life we can change and change them as best we can, accept the things we cannot change, and seek the wisdom to discern the difference between the two.
I’m starting to wonder if less than I hoped is achievable from this grass roots movement. Fortunately I have enough wisdom to know that this cynicism is probably coming from fatigue. I’ve written these posts every day for almost 30 days, despite encouragement from my wife to take a break. I’m reminded of my friend Ira’s advice. He’s a therapist and visual artist spending increasing hours in his studio and increasingly resenting the time at Kaiser which keeps him from his passion. He noticed that when he forces himself to take a brief sabbatical from his photography, upon return he’s a new man. A new artist.
In service to the mental health clients and their providers who need advocacy, I’m taking this weekend off. I’ll be back on Monday. Anyone caught in the midst of this whirlwind, I encourage you to take your breaks as necessary too.
On my first day at Kaiser, my buddy Scott pulled me aside and said, “You’ve got to watch out for Kaiser. They’ll work you to death.” That’s a fact. My colleague Nancy Grelet, on approaching retirement, was literally taken out of the clinic on a stretcher. So we all have to be careful.
Be kind to yourselves. It’s Spring after all. Wake up and smell the roses, the coffee, anything stinky and fine.
See you Monday.(63 days to go.)
OK, People. Make it Work.
Posted on March 29, 2014 by weisskoff
I know. I know. I’m supposed to be taking a break. And I am. I’m taking a break from mandatory daily entries. I told myself I don’t have to write anything this weekend. But I can still do it if I want to, can’t I?
And while I was rowing this morning I got excited about putting out a mission statement for this blog. So here it is. It’s a basic basic standard for providing individual therapy at Kaiser. I’m hoping all Kaiser therapists will embrace this standard so we can promote it successfully. Or, if we disagree, that we make adjustments and move forward with a uniform voice.
Kaiser at large is not going to set a new goal around individual therapy without considerable external pressure. An HMO’s management seeks to maintain maximum flexibility. A commitment to a new standard cuts their flexibility dramatically, and expensively. We’re going to have to set the goal ourselves and promote it using every venue we’ve got.
So here’s my mission. Here’s what I want to be telling future clients over the phone during first contacts. It’s what I want to see announced on our system-wide website, kp.org. It’s what I want to be able to portray with ease to anyone inside or outside of Kaiser about how our department operates.
I want to be able to say:
The adult psychiatry department offers individual therapy to any Kaiser member diagnosed with one or more of the following conditions:
Major Depression (Single Episode), Major Depression (Recurrent), Dysthymia, Depression NOS (Not Otherwise Specified),
Panic Disorder, Obsessive Compulsive Disorder, Generalized Anxiety Disorder, Post Traumatic Stress Disorder, Social Anxiety Disorder, Anxiety Disorder NOS,
Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, Psychotic Disorder NOS,
Anorexia, or Bulimia, and
Pervasive Developmental Disorders.
Hour-long, face-to-face, sessions are available to all Kaiser members who have one or more of these conditions and who have the capacity to decrease symptoms and/or improve life functioning through individual therapy. These sessions are available at least every other week and for as long as the client continues to benefit.
(61 days to go.)
Let the Treater’s Treat
Posted on March 31, 2014 by weisskoff
There are seven therapists on the adult team in Santa Rosa trained to use EMDR to treat trauma. We all want passionately to provide the relief that the therapy affords, but find it impossible to do this work at Kaiser thoroughly and safely.
EMDR stands for Eye Movement Desensitization and Reprocessing. It’s the therapy developed by Francine Shapiro in the late 1980s that is now widely accepted throughout the world as the treatment of choice for Post Traumatic Stress Disorder (PTSD). A few of us EMDR enthusiasts who work at Kaiser, in Santa Rosa and elsewhere, have on occasion found ways to provide this treatment, despite heavy caseloads and minimal face-to-face appointment time availability. Whenever I run into someone at an EMDR training from another Kaiser clinic, we lower our voices and share tales of making the magic happen under the radar.
For those who don’t know what EMDR is all about, I wish I could refer you to my wife’s most excellent memoir, “Responsible Girl,” that describes the process beautifully. But her book’s not quite done. And it’s definitely not quite sold. So it’s not available for you to read today. In lieu of that, I’ll explain briefly how EMDR works.
In an EMDR session, clients deliberately bring to mind the most horrific moments of their lives, while their eyes are guided rapidly left, right, left. Instead of eye movements, we sometimes use headphones with tones that trip back and forth between the client’s ears. Sometimes we use hand-held buzzers. Sometimes we tap or ask our clients to tap their legs or shoulders.
At the same time as employing these forms of bilateral stimulation, we ask the client to describe the thoughts that have nestled in among remembered images and sensations. Often, maybe always, it’s not what a person has seen or done that’s traumatic. It’s how the people around them, in positions to soothe or criticize, react that makes a bad event traumatic. These reactions from caregivers and friends can translate into self-blame and self-loathing. And that’s what people with trauma carry into the room — extreme negative self-talk. And that’s what their individual therapists are responsible for transforming in the therapy.
Over the years I’ve worked with people who, when young, were brutalized by alcoholic, mentally ill, or just plain cruel parents. I’ve worked with adults still haunted by sexual assaults from family members that, in many cases, persisted for years. Many who had difficult childhoods continue to be harmed in their adult relationships, creating additional layers of traumatic memory. In the simplest cases, people are traumatized by a single life-threatening incident they experience as an adult — like being kidnapped and raped, or like witnessing your best friend’s child killed by a falling tree.
The worst things imaginable happen routinely. And the survivors come to therapy craving relief.
These are the kind of people that EMDR was designed to treat and treat quickly, people with nightmares and day terrors that continue years after they escape the abusive or terrifying situations. Before EMDR, people with PTSD were told by clinicians to try to forget their experiences. Nothing comes from reliving and revisiting, they were told, so it’s best to turn away. But they could not forget what had happened to them. And that’s why when EMDR came along it was such a miracle, for therapists and clients alike. It helped people soften these memories so that they became tolerable to live with.
And that’s why it’s critical for Kaiser to provide its clients with PTSD access to EMDR. The therapy works. Nightmares vanish. Relationships improve. Joy emerges.
If a person with a vicious trauma history can summon the bravery to bring their experiences into the open. . . . And if that person is lucky enough to find a therapist willing to review with them these hellish memories, to guide them surely out. . . .
Shouldn’t Kaiser be doing everything in its power to support their efforts?
(59 days to go.)
Posted on April 1, 2014 by weisskoff
A brand new Kaiser member is automatically assigned a primary care physician (PCP). If, somewhere along the line, you don’t like the one originally assigned, you can ask to switch doctors. On the kp website are photos and profiles written by each of the PCPs to help you find a better match. But when you call in to make the switch, the doctor whose profile you like may not be available. That’s because the medical center uses an algorithm to determine when a doctor is overloaded, and closes their “panel” when they are. I imagine this algorithm includes issues like accessibility — for appointments in the clinic, phone calls, emails. There must also be a standard acceptable ratio of patients per doctor, spelled out in the State’s health care codes. Then there’s the issue of creating customer satisfaction, very important in a competitive health care world. So, for a bunch of reasons, there’s a structure in place to address the ebb and flow of patients within each PCP’s caseload, and to ensure that doctors are always available.
We have no such mechanism in Psychiatry. No caseload cap for therapists. (No cap for psychiatrists either.) Instead, therapists have a constant in-flow, somewhere between one and five clients a week, and no one to listen when we cry uncle. I’ve worked at Kaiser 7.5 years. At four clients a week, I have approximately 2000 clients on my caseload. Of course I don’t have 2000 active clients. They’ve come and gone over the years, as a result of changes in their symptoms, life events, insurance coverage.
But also, and this is where perverse incentives come in, people come and go according to my accessibility. What happens when a line is too long? We give up waiting for whatever’s at the end, right? Clients, when they discover there’s a one month wait to be seen again, drop out of treatment. In a way, therapists, too, drop out of participation in our clients’ treatment if we don’t have reasonable access. When I know my next available appointment isn’t for two months, I change my expectation about what I’m offering. I certainly won’t start somebody on EMDR. I might recommend the client seek therapy outside our department. (These days that suggestion is accompanied by another recommnedation, that they complain to the DMHC.)
Perversely, when clients and therapists give up for a period of time, the waits go down. Suddenly it seems like things aren’t so bad. But then we act as if these relatively reasonable appointment waits will last forever. We go ahead and provide services, and, in no time, we’re back where we started. So people drop out again. And therapists despair again. And around and round we go.
This might not matter so much if, when the lines were long, our clients merely took a break. But they don’t just take breaks. They drop out of treatment altogether. Much to the delight of the system and the chagrin of us therapists.
Why do primary care physicians get to open and close panels and we do not? The two main reasons I imagine are (1) health codes spell out how available primary care physicians need to be, but they are less clear about therapist and psychiatrist availability, and (2) the corporation views PCP availability as a cost-efffective means toward creating customer loyalty, but they view psychotherapy only as a moneypit. No matter how many visits therapists offer, consumers will use them up and want more, kind of like massages.
If we are going to get any traction on this issue of providing individual therapy, we need the structural equivalent of open and closed panels. And before Kaiser goes for that, they’re going to have to see us as more vital than a spa.
(58 days to go.)
Slowing Things Down
Posted on April 2, 2014 by weisskoff
I went to work today excited and horrified by my plan to send the following email to every single Kaiser employee in the Santa Rosa Medical Center — from the physicians to the groundskeepers. The gods intervened, I assume on my behalf. I was not granted access to the “SEND ALL” group lists. Mildly daunted, I found an old paper list of providers and one by one addressed the message to about fifty non-MD clinicians who probably don’t know about this blog and its goals. The fifty are physical therapists, nurse practitioners, nurse midwives and acupuncturists who work in Santa Rosa. Though slow, this somehow felt more personal and more satisfying than a group blast.
Next stop is to find a way to send this email to our nurses. Their numbers are vast, and they are, by nature, good people and spreaders of the word.
Happy April to my friends and colleagues of the Santa Rosa Medical Center!
I’m a psychotherapist who has been working in the Adult Psychiatry Department up on Round Barn since September 2006. I’m leaving Kaiser in two months because I can no longer safely and effectively provide individual therapy to our members with trauma. But on my way out, I’m determined to improve the system so that Kaiser therapists can start offering the kinds of treatment we are trained for and that our members deserve to receive.
Psychiatry Departments throughout Kaiser, including in Santa Rosa, have never offered individual psychotherapy at a level consistent with community standards. It is widely known that we mostly provide assessment and referral to groups. A year ago, the Department of Managed Health Care stepped in and told Kaiser to start providing the kinds of mental health services that the Knox-Keene and Parity Laws demand, including individual therapy.
As a result of this intervention, we stopped telling our members that we don’t provide individual therapy. We removed this language from our on-line and printed literature. But we have yet to begin offering face-to-face individual sessions at a frequency useful to our members. In fact, the time between individual sessions in Santa Rosa has only gotten worse with the expansion of MediCal and the advent of Covered California. The current wait time between a first session with a therapist and the next appointment with the same therapist averages 30 days, regardless of the seriousness of a client’s condition. It can be twice as long if you are a monolingual Spanish-speaker.
If you want this situation to change, there’s something you can do to help the Department of Managed Health Care complete the work they started last year, the work of bringing individual therapy, finally, into our clinics.
I created a website called 90daystochange.com to encourage members who have been denied sufficient individual psychotherapy at any Kaiser mental health clinic to report their challenges. There’s a button under the heading“Kaiser Mental Health Clients, Family Members, and Friends Speak Up”which gives instructions on how to report directly to the DMHC.
Why am I sending this message to all of you? As Kaiser members, many of you have sought mental health services for yourselves or for family and were unable to get the care you needed, starting with adequate time to build a relationship with a primary therapist. Additionally, in your various roles throughout the hospital and in our clinics, you also come in contact with numerous members who need individual therapy, but can’t get it, because we don’t provide it.
I’m recommending that anyone who has tried to get face-to-face time with a therapist in our department in the last year, but found the wait times between appointments too long to be helpful, report your challenges to the DMHC. I’m also recommending that you encourage anyone you come in contact with as an employee with similar struggles in the past year to report as well.
Why am I suggesting this today? The DMHC currently has its eyes on mental health services at Kaiser. In May, they are scheduled to meet Kaiser in court as TPMG attempts to dismiss a $4 million fine for denying access to mental health care. The DMHC can use all the help they can get to hold Kaiser accountable. At the same time we need even more oversight from the DMHC to create a new standard of care within mental health, specifically around individual therapy. Without new guidelines, we can only expect business as usual.
I have loved my time as a therapist on the adult team at Kaiser, and working with so many of you throughout the medical center. I created the website and am sending this message to expand the quality care we already provide in most areas of the medical center to mental health.
Please speak up. And the sooner the better.
Andy Weisskoff, LCSW
(57 days to go.)
Posted on April 3, 2014 by weisskoff
I got some more details about Kaiser Oakland therapists and what they’re up to. They’re threatening to strike mid-April unless their bosses roll back at least two very significant, recent policy changes.
The first change involves their on-call system. On-call deserves its own post. Perhaps someday I’ll get around to it. But for now, the basics are that it’s in our contracts to provide on-call services to Kaiser emergency departments throughout California. This means that when a Kaiser member needs an evaluation for psychiatric hospitalization in the ER after 5PM and before 8AM on weekdays, and on weekends or holidays, whoever is on reports to the hospital to make the assessment. Of significance, with the increase in MediCal clients and Covered California clients, on-call assessments have become both more complicated and more frequent.
Psychiatry Departments throughout the State structure on-call in different ways. In some clinics the work is shared among all therapists on a rotating schedule. That’s how we do it in Santa Rosa. For us it’s typical to have one shift a month or so. That might sound like no big deal. But, unless we take vacation time before or after a day shift in the clinic, we might work 40 hours or more in a row. To protect the safety of patients, there are legal limits to the number of consecutive hours physicians in the ER can work without a break. Not so for therapists. There are no limits in place that might protect clients from very sleepy therapists making life or death decisions about their care.
In Oakland, a group of 5-7 therapists was doing this on-call work until administration decided they wanted to change it up. They announced that everyone on the team was going to start doing on-call, and that they were going to share the work with Richmond (a neighboring city), so that in the same evening therapists were expected to bounce back and forth between the two ERs. A functional system was replaced, without therapist buy-in, by one that sounds, on the face of it, disastrous.
The second significant change Oakland therapists are protesting is that they now have less time for initial assessments. Many of us structure our schedules so we have 90 minutes for the first interview, for planning with the client around their future care, for charting, and for communicating with other elements of our integrated system. (A few psychiatrists take 90 minutes to do this as well.) As if it’s not hard enough to establish a connection with a stranger in 60-90 minutes, Kaiser Oakland has instituted a cluster interview system that reduces this time to 45 minutes. They started overbooking initial appointment slots. And if everyone shows up, some unlucky therapists and clients are given half the time to meet, bond, and form a plan for continued services. Two clients in a 90 minute block. Not good.
I suspect it’s unprecedented that a group of Kaiser therapists is using the threat of a strike to try to change policies that are unsafe for clients and staff. And, as you can imagine, we’re all watching to see what happens next.
(56 days to go.)
Come Out, Come Out, Wherever You Are
Posted on April 4, 2014 by weisskoff
It was a little like stepping through the looking glass, coming to Kaiser from private practice. In private practice, the therapist advertizes like crazy: I’m open for business, come on in, I’ve got a sliding scale, I’ve got chocolate, the first session is free. Et cetera. At Kaiser, the therapists and psychiatrists try not to be found. And once found, perverse incentives drive us to be of as little help as possible so people don’t want to find us again. (See my post “Happy Endings” from a few days ago.)
I was talking to my boss the other day about the large variance among therapists in our wait times between appointments. If you meet with a therapist for the first time today, for example, your next appointment can be in as few as seven or as many as sixty days in the future, depending on which therapist you meet with. Some of this variance is explained by the fact that our panels are permanently open. Therapists who have been here longer tend to be more backed up. But even this rule of thumb is inconsistent. The same veteran therapist may be backed up three weeks one month and six weeks the next.
So what’s going on? (My boss was curious too.)
I’ll tell you what happens with me, and I bet it’s happening with others. When I come in on a Monday, see a new client, discover that my next available appointment isn’t for six weeks, I shift my strategy for a while. I may not book any follow-ups at all, except in the most acute situations. Not booking a follow-up isn’t really a strategy. It’s more like throwing in the towel. In those lean times I make my apologies and explain this is not how we therapists like to do things. And after a month of only providing assessment and referral to groups, my follow-up times drop down significantly.
I think I’ve made it clear that this manner of managing a schedule is in no way client-centered. It is driven exclusively by the therapist’s stress level, our fear that the waits between sessions have gotten too long and we must do something drastic to restore balance.
I got an email a couple of months ago from a psychiatrist working at the San Rafael Psychiatry Department. Kaiser San Rafael is 38 miles down the 101 from Kaiser Santa Rosa. One of this psychiatrist’s patients had come to me for EMDR and improved dramatically. (Kaiser members are permitted to receive services at any Kaiser.) The psychiatrist wanted to know how this miracle of quality service had been accomplished. In San Rafael, the norm is assessment and referral to group. No individual therapy, and certainly no EMDR.
I let him know that several of us therapists in Santa Rosa had put one or two longer sessions into our schedules (90 minutes vs 60 minutes). New EMDR clients have to wait the one to two months for our schedules to clear before we can see them, but then we book several sessions in a short period of time. Before deciding to quit, I had been scheduling three sessions in a two week period — one is 90 minutes, the other two are 60. This method of delayed scheduling is feasible for people who have been living with PTSD symptoms for years and don’t need immediate relief. But it’s not so useful for people who have just experienced something traumatic, like a shooting, and would like to be seen more quickly than one or two months from the incident.
The psychiatrist, clearly a guy who cares and is trying to get treatment for his people, wanted to refer his PTSD patients to Santa Rosa. I told him please don’t. I let him know we can’t keep up with the referrals we get from within our own clinic. But the word is out, from this psychiatrist and from our clients who have benefitted already.
They’re doing EMDR up in Santa Rosa.
What happens next once this message is out? People who have heard about us request EMDR from the phone triage therapists. The specialists in EMDR watch our schedules fill up with very complicated and exhausting (and gratifying and edifying) cases, and we get backed up to the point where we cannot function. So then what do we do? Announce to the clinic: sorry we can’t do EMDR for a while, not until our schedules clear up. Then we wait until the situation improves. After a while we dare come out of hiding to serve the few people lucky enough to ask for help on a day we’re not buried under the covers.
Then, once again, we go back into hiding.
(55 days to go.)
We Work in the Dark, We Do What We Can
Posted on April 6, 2014 by weisskoff
This weekend I wrote a long editorial for the New York Times. Sadly, according to their bylaws, they won’t consider publishing it there if I post it here. Which leaves me with quick updates and paranoid observations for today’s post.
The most exciting update is about two communications I received today, one from a therapist, one from a consumer. The therapist, who works at a Northern California psychiatry clinic, confirmed that she shared the experience of many therapists in Santa Rosa – chronic understaffing, having time to provide only a minimum of care, and feeling right on the edge of quitting. She did not want to post her story here, even anonymously, or, for that matter, for me respond to her personal email, for fear that Kaiser will somehow trace the communication and strip her of her job.
The consumer did post her comment, which you’ll find under the tab “Kaiser Mental Health Clients, Family Membbers, and Friends Speak Up.” She plans on calling the DMHC Monday to report her experiences, but also asked to remain anonymous. I encouraged her to write back after she calls, and to post what she discovers about the process.
As I continue to step away from my career at Kaiser, the extent of intimidation felt by therapists and clients alike is increasingly apparent. My colleagues these days assume every keystroke is being monitored, and wonder if our phones are tapped. Clients believe that if they attempt to advocate for themselves in any form, they’ll lose the little help they’ve gotten to this point.
I can see now that this is not mere paranoia. Staff, including MD owners of the corporation, do lose their jobs for speaking up. Clients do get subtlely blacklisted from receiving services.
I’ve made several attempts to engage the press to discuss these issues. I’ve written editorials to the San Francisco Chronicle and the LA Times. They were well-written and didn’t sound, I don’t think, like the ravings of a disgruntled employee. Our local independent paper, the Bohemian, is to date the only publication willing to air my views. (See http://www.bohemian.com/northbay/the-patient-trap/Content?oid=2573083.) I’ve communicated by email with a reporter for the Santa Rosa paper, the Press Democrat. He initially expressed interest in hearing more, then his enthusiasm dried up. I saw his by-line earlier this month on an article about Kaiser receiving top scores from consumers according to JD Power. (http://www.pressdemocrat.com/article/20140310/business/140319951). His silence now makes me wonder if the Press Democrat is only permitted to publish flattering stories about the hand that feeds it.
This wouldn’t be altogether surprising. Kaiser is huge. Gigantic. Really, really big. They advertize everywhere and papers desparately need the money. Public radio may similarly be hamstrung. They’re running “Thrive” ads sometimes hourly. Can they afford to challenge Kaiser’s behavior directly?
It may be all we’ve got, these little blogs, to spread the word and to make a fuss. In the first month, 90daystochange.com got over 6000 views from over 1500 visitors. And I know you’re not just random, disinterested parties reading. So maybe it will be enough.
In any case, we’re not through yet. Not by a long shot.
(53 days to go.)
Are You With Me, Dr. Wu?
Posted on April 8, 2014 by weisskoff
Not too long ago one of my therapist friends was talking to one of his doctor friends about the not-so-egalitarian nature of Kaiser services. My friend was pointing out how administrators and physicians seem to get super special treatment when in need, whereas the rest of the population gets, well, less. The physician said, “What do you expect? We own the dealership.” Which ended the conversation.
Today I wrote to the physicians of The Permanente Medical Group (TPMG) who I’ve collaborated with over the the years, exchanging emails, discussing clients over the phone and in person. It’s my first attempt to reach out systematically to the insiders with real power, the ones who own our dealership.
I wrote to about 150 MDs in the Santa Rosa Medical Center – Primary Care Physicians (45%), OB/Gyns (20%), Internal Medicine docs (10%) and Emergency Room docs (25%). Here’s what I wrote:
Friends and Colleagues,
We have shared many patients over the course of the almost eight years I’ve been working on the Adult Psychiatry Team in Santa Rosa. You may know that I’m quitting soon, and that I’m quitting because I am no longer able to provide the services that members with serious mental health problems need and deserve.
Please see my blog 90daystochange.com for more information. I am not pursuing a union agenda by writing to you. And, by speaking up, I’m taking real risks, for example of being fired prematurely and losing whatever pension I might receive upon reaching retirement age. I take these risks because the situation is dire.
Kaiser is the number one provider of mental health treatment in California. Whatever we provide is what the majority of people with mental illness are going to get. And it is not nearly enough. Currently the wait time between individual therapist appointments is, on average, 30 days. As you picture yourself, your family, your friends, in need of emotional support, does this sound like a reasonable wait time between individual appointments? Due to these excessive waits, our primary strategy is to make an assessment and referral to one of our skills groups. But longitudinal evidence, collected in our clinic, shows that only a quarter of those with diagnosable mental illness follow through with these groups. The rest drop out. Does that seem like the best a system responsible for treating the majority of mental illness in the State can do?
The Santa Rosa Medical Center’s Psychiatry Department is not unique in these wait times or in our failure to get clients to follow through with groups. I’ve been in communication with clinics throughout Northern and Southern California. Some places are worse, but nowhere is significantly better.
We are privileged at Kaiser to have an advanced electronic infrastructure to allow communication within departments, between departments, and across disciplines. With all this elegant architecture, we have the least actual communication of any system of care I’ve worked in over the thirty years I’ve been in the field. (I’ve worked in complex systems, at the VA in Palo Alto, and county mental health departments in both San Francisco and Sonoma.) Here at Kaiser we have the ability to communicate, but no time to communicate. We have services set up to support emotional change, like excellent skills groups, but no staff to guide clients through the painful, lonely process of recovery from emotional overwhelm.
I’m doing what I can to alert State regulatory agencies that our staffing is inadequate in mental health, and to encourage patients to do the same. It’s time for you, the physician owners of TPMG, to start speaking up for what you think is right, that is, if you think the current understaffing is wrong. I know the corporation has organized itself to make it difficult and terrifying for anyone to speak up, doctors included. But you are intelligent, warm, and brave souls. Where there’s a will, there’s a way.
If you’ve ever noticed that you’d be willing to earn less in order to work less, or thought that maybe your administrators, from the CEO on down, earn a disproportionate amount of the wealth that KP generates, you can start talking these ideas over with your colleagues. Together you could start brainstorming strategies to change the system. But please do this carefully. I know doctors who have been fired for taking a stand counter to the party line.
I’ve enjoyed working with all of you and am sad to leave. I believe the care we provide is close to being the very best we can offer. But, if our behavioral health programs are to be truly functional, you (the physicians group) need to find a way to fund face-to-face time with therapists.
If you’re looking for a way to safely promote change from within, feel free to contact me via email at firstname.lastname@example.org. I’m happy to set something up on the web for physicians to communicate with each other without fear of retaliation.
Once again, it’s been a pleasure and an honor working together.
Andy Weisskoff, LCSW
(51 days to go.)
Let’s Trade Secrets
Posted on April 10, 2014 by weisskoff
There I was, thinking I was losing interest and steam, starting to turn my attention away from Kaiser, looking for new office space and updating my liability insurance. But then I got two emails from my buddies at the National Union of Healthcare Workers (NUHW) and SHAZAM!
The first came last night with the great good news that Jenny Ming, a member of the Board of Directors for Kaiser, has announced her resignation. She was specifically targeted by the NUHW because her company, Charlotte Russe, is under investigation for ongoing health violations – they’ve been making clothes for young women using lead-based paints. I found this article on our local public radio website http://blogs.kqed.org/science/2013/12/24/sf-clothing-company-accused-of-knowingly-selling-lead-laden-products. Jenny Ming is the second member of the board to step down in the wake of NUHW investigations. It’s discouraging, to say the least, that people like this are guiding the country’s most influential HMO. They are, of course, successful business people. I guess to this point, that’s been good enough for Kaiser.
The second email came today, informing me that Kaiser lawyers are attempting to close the public hearing slated to start May 12 in front of an Administrative Law Judge in Oakland. This hearing is the one in which Kaiser hopes to convince a judge that they complied fully with the Department of Managed Health Care’s requirements to improve mental health care, and thus they don’t deserve to pay the $4 million fine. (If you are unfamiliar with these events, please read the first few entries of this blog to catch up.) Anyone who wants to keep these hearings open to the public is welcome to show up tomorrow, Friday 11, for a prehearing conference at the Office of Administrative Hearings at 1515 Clay Street, Suite 206 in Oakland, CA. I don’t believe there will be an opportunity to voice your opinions, but your presence will be extremely valuable.
One of Kaiser’s arguments for closing the hearing is that the evidence being discussed will reveal trade secrets about how they operate. Once these secrets are revealed, the argument goes, other HMOs will adopt their policies and procedures and put Kaiser at a competitive disadvantage.
This is a truly fantastic line of thinking, considering that Kaiser is being fined for NOT having policies and procedures, specifically ones that address the continuity of care for their mental health clients. They do have procedures in place for creating the appearance of care. And I suppose these are what they want to protect by sealing the courtroom. Prior to the DMHC’s interventions, our secret procedures for circumventing legal requirements for timely access were numerous. We had waitlists that hid the numbers of people we weren’t serving, for example. We dissuaded newcomers in a variety of other ways, too, like telling them we don’t offer the primary thing they’re looking for to get relief from their symptoms: individual psychotherapy.
Is that proprietary information, how to make it look like you’re in compliance with the law when you’re not? Are these the kinds of trade secrets that Kaiser doesn’t want our competition to catch wind of?
And my understanding is that the Administrative Law Judge is going to be asking about much more than initial access compliance come May. She’s going to be asking about policies and procedures to address continuity of care once a client is in the door. I hope she wants to know how we monitor the progress and safety of our clients. As I’ve argued here, the most reliable means to address mental illness is to quickly and deliberately establish each client with an individual therapist, someone who knows the client well and encourages them every step of the way. What we do instead of providing our clients with a consistent individual therapist. . . is that proprietary information? Is that a trade secret, how to create the appearance of care, for example, by developing group programs that most of our clients don’t attend?
And then there’s the issue of quality assurance. In our clinic we used to have a multidisciplinary team responsible for investigating suicides, hospitalizations, and other negative outcomes. It’s in the regulatory statutes for Medicare and Medicaid to have these quality assurance systems set up. But Kaiser eliminated our functional, ethical, and legally-mandated review system, putting in its place one MD to review cases on her own. How Kaiser managed to make this switch, under the watch of the DMHC, and despite very consistent and thorough protest of therapists to all levels of the medical center administration… is that proprietary information?
Maybe the secret knowledge of how to keep the DMHC and other consumer protection groups off your back is the kind of information that a judge is responsible for protecting from Kaiser’s competitors. I suppose lawyers can and will argue that any strategy its client uses to remain profitable is proprietary. But I’m not buying it.
Will the judge?
(49 days to go.)
Posted on April 11, 2014 by weisskoff
More good news. Today the Administrative Law Judge (ALJ) in Oakland, upon being presented with Kaiser’s request to make private the hearings to beat their $4 million fines said, swiftly, no. The hearings are to remain public. Nice work, National Union of Healthcare Worker (NUHW) buddies. Once again you’ve earned a luxuriant weekend, though I worry you won’t take one.
I had an unusual occurrence working the triage phones this afternoon. A representative from Kaiser Member Services wanted some information about a specific member grievance. (If you have Kaiser coverage, you’re called a member, whether you like that moniker or not. I find it slightly unseemly.) This particular member had met with one of our therapists and was booked for a follow-up at her next available return time, in six weeks. The therapist encouraged the member to lodge a grievance, but also gave the member some names of therapists in the community, since she believed the member needed more frequent visits in order to recover from her mental illness, even if Kaiser wasn’t going to cover those visits.
Since the Member Services rep had spun the roulette wheel and gotten me, she learned more about the broader picture of wait times than I think she originally bargained for. I even turned her on to this website. She seemed genuinely curious, but who can tell.
The conversation left me uneasy. I was reminded of the problem of squeaky wheels, that if we have too few customers complaining, or if their complaints are spread too thinly, Member Services will provide only finger-in-the-dyke solutions, like giving someone weekly sessions for a month or two just to shut them up.
I found out from this particular Member Services rep a little more about what happens when a client calls the Department of Managed Healthcare (DMHC) directly to complain about long wait times. They are referred back over to Member Services to file a grievance. If this grievance doesn’t have the desired squeaky wheel effect, if the member doesn’t get the resources they have requested, they are redirected to the DMHC, who investigates the matter at that point. If the DMHC believes the squeaky wheel deserved some grease, they fine Kaiser on the spot for misbehavior.
Here’s my analogy. Imagine that a whole wing of a hospital drops off a cliff. (It’s OK. It happens at night. No one’s hurt.) Unfortunately, everyone who was receiving services in this wing has nowhere to go for help. The hospital decides they’ll wait until they’re told, “Members are suffering. You must rebuild,” by the regulatory agencies who say such things, before they start redesigning. But the regulatory agencies don’t go looking for problems. They wait to hear if the wing that fell off the cliff was actually doing anything important before they start advocating.
“Hello. I was being seen at that clinic that fell off the cliff?”
“Did you call Member Services?”
“Should I? My clinic fell off a cliff.”
“Yes, of course. Call Member Services and lodge a grievance. Even if the clinic is gone, they need to take care of you anyway. Call us back if they don’t offer you a satisfactory alternative.”
“I’m calling back. Member Services wanted me to let you know that they’re very sorry, they can’t help me because their clinic fell off a cliff. They have plans to rebuild by 2018.”
“That’s no good. You need to be seen sooner than that. We’ll fine them a thousand dollars. Maybe that’ll speed them up.”
With the advent of MediCal expansion and Covered California, our tenuous ability to provide individual therapy has fallen off a cliff. And there doesn’t seem to be a system capable of responding comprehensively to this comprehensive disaster. Somehow we need to get enough individuals to grieve the problem at once, or we need to develop a separate channel for communicating the breadth of the problem, if we want the DMHC to move forward to address the whole system at once.
If we can’t muster a large enough outcry to what has been lost, the assumption will be that our members never needed individual therapy in the first place. And that, as we know, is just not true.
(48 days to go.)
Posted on April 12, 2014 by weisskoff
I sent this message today to Marta Green, a Communications and Planning Director with the Department of Managed Health Care (DMHC). We had some back and forth emails ending on March 19. She didn’t respond to my most recent email, sent on March 31, asking her how consumer reporting was going.
I’m grateful that the hearing in Oakland, slated to start May 12, is going to be kept open to the public. Considering that Kaiser is the number one provider of mental health services in California, there’s a lot at stake, and the public has a vested interest in the process being as transparent as possible.
I’m concerned that the advice some of us therapists have been giving our clients to report their problems accessing individual therapy directly to the DMHC may not be the most productive way to gather this critical information. I know you’ve heard a lot from therapists about how we view the problem of long waits for return visits. But your role, as I understand it, is to advocate for the consumers, not the providers serving them. I’d like your advice as to how to collect this information reliably directly from the consumers.
Here’s why I’m concerned.
I set up the website 90daystochange.com to encourage Kaiser clients who are having to wait one, two, or more months between sessions to report to the DMHC the effects of these waits on their mental health. But individuals who call the DMHC are being directed back to Kaiser’s Member Services Department, and told to call the DMHC only if things don’t improve through Kaiser’s internal grievance process. Many of our clients will not file a grievance with Kaiser for fear that they’ll be labeled troublemakers and lose whatever services they’re currently getting. So I’m afraid the information about the challenges they are facing is falling into an abyss.
But I could be wrong. Are you recording the information about these consumers’ difficulties, even if they don’t file grievances with Kaiser? And, if so, are you recording it in a form useful toward recommending a new standard around individual therapy?
In the past, I suggested setting up a temporary reporting line specifically for Kaiser mental health clients to have a safe opportunity to share this information with the DMHC. Therapists and other advocates could have directed clients to such a phone line. But you let me know the DMHC did not have the resources for that. Which is why I created the web page I did. Due to the above concerns, I’m wondering if it would make more sense to set up an email box. Those can be free and create a useful paper trail.
Advocates for consumers can direct people who have had health challenges as a result of long wait times to send an email to you. And by the time of the hearing in May, you might have a clear body of evidence from consumers to supplement the therapists’ claims. If the hearing is called off, you could add this evidence to your survey information to justify enforcing a more rigorous standard for individual therapy within Kaiser.
Let me know what you think. One possibility is to have people send their emails to you or another designee within the DMHC. But if you want to set up a separate mailbox, that will work too.
P.S. Full disclosure: I publish just about every meaningful communication with public entities on my website 90daystochange.com. This email to you is in the body of today’s posting. I also tend to publish whatever responses I receive. Including when I get no response.
(47 days to go.)
Where Does The Buck Stop, Here?
Posted on April 14, 2014 by weisskoff
Kaiser California is split into two administrative regions, Northern and Southern. I sent this letter via our email system to the presidents of each region. Their profiles, as developed by Kaiser, are at:
Though their email addresses were available on our Lotus Notes system, it seems unlikely that these messages went anywhere near these powerful men. But, who knows?
Hello Mr. Adams and Dr. Chu,
I’ll keep this note as brief as possible. I’m a psychotherapist quitting my job at the Santa Rosa Medical Center at the end of May, way before retirement age. I’m 49.
I’ve been blogging my exit from Kaiser at 90daystochange.com. Within 6 weeks this blog has garnered 10,000 hits, mostly Kaiser employees and Kaiser members throughout California seeking improved mental health services.
I have been working closely with the NUHW and the DMHC to develop a new standard of care, specifically to increase access to individual therapy hours for those members who meet medical necessity. I believe this change is just around the corner.
I’m writing to appeal to you two to take the lead in moving these changes forward proactively, ahead of the next set of fines from the DMHC, ahead of the next round of strikes by NUHW therapists. I believe it would be the best PR possible if you acknowledged that Kaiser has not historically provided mental health services at the same level of quality as physical medicine services, and that you are now prepared to address this discrepancy.
Prior to this past year and a half I was proud of the essential work I was doing here: providing individual therapy to people with severe emotional trauma. And I would like nothing more than for the system to improve enough so that I could return to Kaiser and resume that work. Anything you can do to hasten that process I truly appreciate, as will the thousands and thousands of people with mental illness currently being underserved by the system in place.
I am available to talk through any of these ideas at any time, before or after I leave Kaiser.
Andy Weisskoff, LCSW
(45 days to go.)
(Half way gone. Half way here.)
We Are Here! We are Here!
Posted on April 15, 2014 by weisskoff
I sent an email to Marta Green from the Department of Managed Health Care (DMHC) a few days ago. (You can see my note on the post “Safe Haven.”) I’m grateful that she was very quick to respond. And with really good news. I was concerned that if clients who were trying to report systemic issues didn’t follow through with Kaiser’s internal grievance system, then their general reports about individual therapy insufficiencies would go unrecorded.
To my great relief MG wrote back:
“Whether or not a health plan member ultimately decides to pursue a grievance with his or her health plan, every contact the Help Center receives is catalogued. These complaints are tracked to identify potential systemic issues at individual health plans and throughout the health care marketplace. Additionally, when the DMHC launches its routine and non-routine medical surveys of its licensed health plans, the survey team reviews the complaint data to help shape potential areas of focus. Therefore, even if a health plan member isn’t comfortable filing a grievance with his or her plan, the information he or she provides to the DMHC is recorded.”
Thank you, Marta. That couldn’t be any clearer.
Which brings me to my Horton Hears a Who analogy. Remember the Dr. Seuss classic? All the Whos down in Whoville are living on a dust speck, about to be destroyed. Only Horton the elephant with his extraordinary hearing knows they’re down there. If they are to survive at all, the Whos must organize. So all its citizens shout at once, “WE ARE HERE!” loudly enough to be heard by the world outside their dust speck.
The challenge for mental health clients at Kaiser is to complain all at once, so the volume becomes a signal against the noise of general dissatisfaction with managed health care. We may need to take out newspaper ads, secure public radio spots, organize social media blasts — all to encourage Kaiser mental health clients to contact the DMHC over a very short time period, so their voice can be heard as one.
Anyone reading this post and feeling creative: think of every way you can to direct Kaiser mental health clients to this site, to the tab for “Kaiser Mental Health Clients,” which gives clear reporting instructions. And, because deadlines are always motivators, how about suggesting people make their reports by May 12, when the hearing between the DMHC and Kaiser is slated to start?
If everyone with mental health needs shouts at once, the DMHC is certain to hear.
(44 days to go.)
One a Day, Every Day
Posted on April 16, 2014 by weisskoff
I sent this email out today to virtually all the Kaiser therapists and psychiatrists who work with adult psychiatry clients in Northern California, about 650 dedicated clinicians.
Hello Therapists and Psychiatrists, Friends and Colleagues –
As you may know I set up a website “90daystochange.com” in order to provide education to ourselves and our clients about the deficits in Kaiser’s mental health delivery system. On that website is a tab labeled, “Kaiser Mental Health Clients, Family Members, and Friends Speak Up.” The page gives detailed instructions on the type of feedback the Department of Managed Health Care needs to hear from consumers in order to enact significant changes.
If these individual consumer complaints are too spread out too thinly over time, I am concerned that they will not be heard as an aggregate complaint. I’m encouraging everyone to set a target of referring one person every day to the reporting line via my website, until May 15. That’s one month.
We do not have to look too hard to find these clients. Whenever someone says, “Four weeks until my next appointment! That’s not right!” Or if they ask specifically what individual therapy in our clinic looks like, and are dismayed to find that we don’t offer weekly therapy, even to people in dire need. Or any time you’re deeply worried about how the client in front of you is going to fare in the weeks between now and your next visit. . . . these are all times you should offer the web address,90daystochange.com, and encourage your client to call the DMHC.
At first I was worried about retaliation for taking such a public stance on these matters. I am no longer. Over the past month I have announced via email to all levels of management within our organization (from Gregory Adams, President of Kaiser Northern CA, and Benjamin Chu, President of Kaiser Southern CA, to the Chief of Psychiatry in Northern CA, to the Physician in Chief of the Santa Rosa Medical Center, to my Department Chief, to my direct managers) that I am encouraging my clients to report directly to the DMHC. I have gotten no feedback whatsoever from management. Certainly no green lights or thumbs up. But much more importantly, no requests to cease, no warnings or threats of any kind.
For therapists: as members of the NUHW and as blowers of whistles about breaches in the laws, we are very protected. If your local management voices any objection to you encouraging your patients to report, you can, of course, stop at that time. There are many levels of disciplinary action before getting fired. The NUHW has made it clear that it would be “wrongful termination” to fire anyone without giving them the opportunity to change behavior. In sum, there is much to gain and very little to lose by encouraging your clients to report. Manyof your colleagues have been doing this for weeks and there have been no reports of retaliation.
For psychiatrists: you are in a different position, and I advise caution. Still, if you believe your clients require individual therapy sessions to improve, I believe it is your responsibility to advocate in any way you can for their care.
So here’s my challenge to you. Every day, find one person you believe deserves a better deal than they’re getting. These people are in your office every day, asking for your help. If you can’t see them as you’d like to now, you can take action to ensure their proper treatment in the future.
(43 days to go.)
How to Make a Bad Movie
Posted on April 18, 2014 by weisskoff
I sent this via email to all clinic staff today. It is the first time I’ve recommended, even obliquely, a change in leadership.
Hello Santa Rosa Therapists and Psychiatrists, Nurses, PSRs, Medical Assistants –
On average, we are still a month out in booking therapist return appointments. Physician return access is dismal as well, though I haven’t systematically been tracking this. Here’s what I believe is getting in the way of providing genuine patient care in our psychiatry clinic. At all levels of administration, Kaiser does not have a healthy balance between health care visionaries and fiscal realists. Everyone in authority seems to be a fiscal realist only. There are no visionairies, at least none on the horizon.
Why is this a problem?
Let’s say you want to make a really good movie. Loosely speaking, there are two forces: the filmmakers (writer/director team) and the film producers. The filmmakers are the visionaries, the ones who are trying to get something beautiful on screen, the ones who pray for their vision to become reality. The film producers are the realistic ones. They’re in control of the budget. They’re the ones who try to bring as much of the original concept as possible to life, but are forced sometimes to negotiate a compromise.
If we had this balance between idealism and realism at Kaiser, clinician leaders would promote a vision of quality patient care, while non-clinician administrators toe the line on budgetary constraints. In Santa Rosa, as in much of the system at large, our Chief of Psychiatry views himself as a “steward of resources,” not as a man responsible for promotoing a dream to improve care of people with mental illness. If our own Chief doesn’t object to one or two month waits between therapist visits, who will?
A year ago, after months of our therapists fighting administrators for more face to face time, when it was finally announced in an all-staff meeting that we were getting four new therapists, we all applauded raucously. Well, almost all. Many of you may remember that both our Chief of Psychiatry and our Medical Group Administrator complained that these new staff were acquired at great “sacrifice,” that patients of other clinics within the medical center were now going to be suffering because our department got these four new therapists.
In Oakland, Kaiser psychotherapists (from the adult, child and family, and chemical dependency teams) are going to strike on April 23 to bring attention to the fact that we don’t have enough time to treat our clients. Coincidentally, Oakland’s Chief of Psychiatry has just announced that he’s stepping down from his position as Chief. My assumption is that he can no longer sustain his role as steward of resources in the face of therapist activism and demands to actually take care of our clients.
Kaiser therapists have reached a flashpoint. Other clinics throughout the State, including ours in Santa Rosa, are expected to join Oakland in announcing strikes to improve patient care. Though the specific structures being challenged, clinic by clinic, may differ, our overarching complaint is the same. Kaiser does not prioritize face to face time with its therapists and psychiatrists. And since no one in management is leading the charge to do so, therapists must.
I address this message to all the physicians in our clinic who have taken on leadership roles over the years, including our current Chief. Please take responsibility for steering us toward actual treatment of our clients and away from the mere appearance of treatment. To avoid further deterioration of services, I suggest that every single adult team meeting (every other Tuesday) and every Thursday meeting, for the foreseeable future, stay focused on this one issue: how are we going to increase face to face time with clinicians to a therapeutic level?
While this is a very complicated, multilayered problem with no simple answers, there are many conceivable solutions. Together we can find a reasonable compromise between a vision of adequate mental health care and the fiscal realities. But there will be no movement forward without the visionaries among us bravely stepping forward to lead the charge.
(41 days to go.)
The Start of a Revolution
Posted on April 20, 2014
I was wondering how to support Oakland therapists in their strike this week. I’ve been unsuccessful at getting editorials into major newspapers. But maybe our local public radio affilliate would be willing to let me do one of their two minute “Perspectives” spots. Here’s what I sent in to KQED. I’m hoping it could run this Wednesday, the day of the strike.
You may already know a piece of this story.
Over sixty psychotherapists who work for Kaiser Permanente in Oakland are walking off their jobs today. You may also have heard that the reason they’re striking is because they don’t have enough face to face time with their clients. Or perhaps you’ve heard that they’re angry about a long, unsettled contract. Both of these things are true.
What you don’t know is that Oakland’s one day strike is, in fact, just the first of many actions Kaiser therapists throughout California will be taking in the next few months on behalf of our underserved clients.
Across the state the wait time between face to face appointments with therapists is currently 4-8 weeks. That means that if you see a therapist today for the first time, even if you have suicidal thoughts, even if you are a veteran of wars with PTSD struggling to pull your life together, you won’t see the same therapist again for, on average, a month. With few exceptions, this shameful statistic is true throughout the entire state.
I’m a Licensed Clinical Social Worker, a psychotherapist, who has been working for Kaiser in Santa Rosa for almost eight years. About two months ago I announced I was quitting when it became become clear that I could no longer safely and effectively treat my individual clients due to the long wait times between visits.
I’m leaving at the end of May. In the last few weeks I have left, I’ve been devoting my energy towards transforming the way Kaiser delivers mental health care to its members. I created a website in order to give Kaiser mental health consumers the opportunity to document their lack of treatment. The website directs Kaiser members to the Department of Managed Health Care, the State regulatory agency in Sacramento responsible for oversight of managed care. Thanks to the consistent encouragement of Kaiser therapists, this State agency is now receiving multiple calls every day.
I’m not doing this advocacy work single-handedly. Kaiser therapists, with the help of the relatively young National Union of Healthcare Workers, have been challenging Kaiser for the last three years. But therapists have recently hit our flash point. And what you can expect to see next, from San Diego to Santa Rosa, is a series of demonstrations, challenging the unacceptable treatment of mental health clients within managed care.
With a perspective, this is Andy Weisskoff.
Andy Weisskoff is a psychotherapist and writer living in Sebastopol, California. His countdown blog, 90 Days to Change, has received over 9000 visits since its start in March. His last day with Kaiser is on May 30.
(39 days to go.)
Posted on April 22, 2014 by weisskoff
Yesterday morning there was a note attached to my door. The Chief of Psychiatry for the Santa Rosa Medical Center said he wanted to see me in his office after lunch. While I’ve been expecting some kind of confrontation with him since I started this blog, the note still took me by surprise.
I had already come to terms with the consequences Kaiser as an institution could throw at me for blogging publicly about their misconduct. They could fire me early, for example. They might mess with my pension. They might try to sue me for defaming their brand. My wife and I accepted these potential consequences before I began posting. And I’ve gotten less and less worried about them over time. No matter what I’ve written, I’ve only received the institutional equivalent of the silent treatment.
The only fear I still struggled with was of pissing off my local bosses and being bullied in retaliation.
The Kaiser corporate system operates on cash incentives. Departments and individuals get bonuses according to their ability to meet goals established higher up the chain. Therapists have been messing with our bosses’ bonuses for a while now. It started when we brought down $4 million in fines by bringing the DMHC’s attention to our employer’s many misbehaviors around client care. The bonus structure must have absorbed at least some of those $4 million in losses, which must have disappointed at least some managers.
And since then, therapists have continued forcing Kaiser to spend more and more money on the only significant line items in a psychiatry department’s budget – staff salaries and the rent to house the new staff. Prior to NUHW intervention I imagine our Chief of Psychiatry, and the Chiefs in other Kaiser medical centers, were pretty much left alone to do as they pleased, and were given their yearly bonuses as long as they held their local budgets steady. But last year, after 14 years without any increase in staff, in Santa Rosa we got four new therapists. Price tag: at least half a million dollars a year. And we’ve gotten more new staff since. And our demands keep coming. We’ve become voracious in our desire to bring services to people who need them. And bolder in our use of direct strategies to make it so.
How has Kaiser been trying to slow us down? In Santa Rosa, they got rid of our most potent advocates within management. Both of our team leaders, consummate psychologists, who collaborated for decades with therapists and psychiatrists to develop all the programs our department provides, resigned last year. Among other harassments, they had been ordered to find ways to turn therapists against each other, to divide and conquer. When they refused, their lives were made so uncomfortable that they decided to leave. Both are really happy now. But the message was clear. If you try to call the shots, we’ll make your lives hell.
So that’s what I’ve been afraid of – an emotional confrontation with one or more of the administrators whose paychecks are being threatened by this blog. Turns out, nothing like that happened in my Chief’s office. And because I prepared myself for the two hours before the meeting, visualizing surviving his rage, I’m no longer worried about being bullied. I can always wait out a tantrum. I’m a therapist, for God’s sakes. And a dad. Angry rich people trying to hold on to their bonuses won’t change the course I’m on. It won’t change the course all of us determined NUHW members are on.
In our Chief’s office were two men — our Medical Group Administrator (a non-MD business director for the medical center), and our Chief. The Administrator handed me the written policy around using the corporate email system. In particular he brought to my attention the part that said I need a supervisor’s permission before sending a group email. (I’d been mailing out hundreds of messages to primary care physicians and psychiatry staff throughout Northern California). I told him I didn’t know about that policy. I told him I wouldn’t send out any more group emails. He said, “Thanks.” And that was that.
So, the worst thing I had been imagining happened – a face to face confrontation with people whose salaries I’m threatening by blogging. And I’m still here, typing away. And, hey, guess what? Oakland goes on strike tomorrow. Don’t forget that. And it’s not like I’ve run out of ideas on how to promote positive change for mental health clients in the Kaiser system.
And I’ve still got five weeks.
(37 days to go.)
Sharing is Caring
Posted on April 23, 2014
Here’s some coverage of today’s strike in Oakland. I think it catches the flavor of the therapists’ protests, and also the attempts of administration to make it seem as if our efforts are strictly motivated by “labor disputes.” Which, I think they’re trying to get the public to believe, means we’re only exposing Kaiser’s midadventures to increase our salaries and benefits. And patient care doesn’t really matter to us.
(I take back anything nice I said in previous posts about Dr. Mordecai, by the way.)
If you’d like an antidote to corporate cynicism… everybody, EVERYBODY, watch this video:
What I love about “Walk off the Earth” is that they share. They share their brilliant, live recordings on youtube. They also share their stage with other talented musicians to help them along. And look how happy they are as a result! (If these guys aren’t happy, they’re really good fakers.)
And there’s no conflict between their kindness, their generosity, and their success.
Get it, corporate Kaiser? You’ve got more than enough. It’s time to share. We know you don’t want to, but it’s no longer your choice.
(36 days to go.)
Visualize This, Baby! — Posted April 24, 2014 by Weisskoff
Media coverage of the Oakland strike reminded me that Kaiser’s spin on why therapists are protesting has been consistent and will likely not waver — that we are only striking to improve our position at the bargaining table. (Listen to KPFA’s coverage of the strike at: https://dl.dropboxusercontent.com/u/87334707/MP3/2014-04-3-KPFA-STRIKE.mp3)Picketers are often self-serving, fighting exclusively for decent wages, for example, so the public may indeed believe therapists, too, are only agitating to get better wages and benefits.
My intention for this 90daystochange website was to create a straight line of communication between mental health consumers and the DMHC – to get rid of the possibly confusing aspect of having therapists in the middle. The hope was (and still is!) that with a flood of reports coming directly from underserved clients, the DMHC would have improved political leverage, and that they might be able to enforce standards of care in addition to the initial access standard they moved on last year with their $4 million fine.
It dawned on me yesterday that a significant problem with these self-reports is that, by design, they’re private. While confidentiality protects the individual reporters, there’s no public paper trail, and therefore less accountability. I think we might need a more public display of consumer disaffection to complement the private one — a message inarguably from consumers alone.
Here’s what I came up with on my walk in the woods yesterday, while Oakland therapists were striking.
Allow, encourage, facilitate other forms of client protest that will be more media friendly, particularly on-line media friendly . I don’t know exactly what these protests will look like, but here are some possibilities. We therapists are big on visualizing. So…
Imagine groups of clients, people who have recently been given follow-up appointments one or two months into the future, sitting down in the lobbies of their Kaiser Psychiatry clinics and refusing to leave until they’re offered something more reasonable.
Or imagine our clients “picketing” outside Kaiser, demanding reasonable access to quality care, instead of the therapists picketing for them. (We therapists could bring the donuts and the t-shirts saying, “Can I have a sooner appointment, please?”)
Or imagine handing clients maps with directions to specific Kaiser officials’ offices – the administrators in charge of quality care, the ones in charge of the budgets. The clients with one or two month waits between appointments could sit outside those offices until they get some direct response about why they’re not getting the treatment they paid for and are entitled to by law.
Would Kaiser administrators eventually call the police to escort their own members off the premises? How’s that going to look on youtube?
(35 days to go.)
Posted on April 27, 2014
I’ve been off of work for five days now. When I return tomorrow I’ll have about thirty days left before I leave Kaiser. I’m starting to feel both the pressure to take a final stand and the relief of an end in sight. Soon this exercise in constant assertiveness will be over.
On my walk in Armstrong Woods this morning I thought of two ways to bring the discussion of Kaiser’s inadequate mental health services more fully into public awareness. My editorials to major newspapers have been ignored. And I’m getting the impression that the tale of Kaiser’s underserved client population isn’t considered “news” yet.
I pictured two kinds of video productions. The first one I’d love to see on YouTube but have no idea how to make happen. I imagine a relatively short video – five minutes or so – featuring a string of Kaiser mental health clients from all over California. There could be a common theme repeated by all the participants, as their individual faces change. “I’m struggling with anxiety [for example] and need help from a therapist. I went to the Kaiser clinic in Santa Rosa last Tuesday and saw someone I really liked. But her next available appointment wasn’t for six weeks [for example]. Now what am I supposed to do?” The sequence could be repeated over and over for the length of the video, creating the cumulative and accurate impression of a common experience among many, many Kaiser members.
I hope this first project appeals to some videographer, maybe a family member or friend of a mental health client, preferably someone who knows how to use the internet and editing software. So if anyone out there wants to develop this idea, or another one to further publicize the issues, and you think I can help, email me at LCSWAndy@gmail.com. I can outreach potential participants through a post on this website as necessary.
The second idea I think I can actualize on my own.
I’ll break out my barely used camcorder and record discussions with Kaiser members, one at a time, and post the videos on YouTube with links to this website. I imagine these would be short segments, just long enough to document the common experience of Kaiser members seeking services for basic mental health challenges but being turned away from individual therapy in droves.
I thought about recording these videos in my Kaiser office as part of a therapy session. I’m “allowed” to set up appointments with current Kaiser members for any therapeutic purpose, even if I’ve never met with them individually before. One of our most common and potent interventions we use is coaching clients to assert themselves in situations that make them feel powerless. I teach this practice one-on-one and we have modules in many of our skills groups that teach assertiveness as well. So it’s not much of a stretch to have an appointment with a new client with only this purpose in mind — allowing someone who feels disempowered to practice what they can do to affect their situation, in this case by lodging a public protest.
But I suspect there would be issues around informed consent if I were to make any type of recording during a Kaiser visit, and those issues would shut the project down pronto.
Instead I’ll put out this offer. Anyone willing to get their face and voice and story on video, I’m willing to meet you to make it happen. In my home, in your home, at a café, in a park, wherever you’re most comfortable. And if you don’t like the way it turns out, I’ll erase it. If you freak out a week after it’s been posted, I’ll take it down immediately. I’ve done that with several written comments to this blog, put them up and taken them down an hour later at the writer’s request.
Your story does not need to be complex or heartbreaking to be powerful. It just needs to capture the essence of what’s happening right now at Kaiser. The most basic tool any one of you needs to recover from strong emotional experiences is a strong alliance between yourself and your therapist. The ability to form this alliance is currently being systematically withheld. Kaiser executives consider individual therapy too expensive to properly fund, and the physician owners of The Permanente Medical Group aren’t stepping in to demand a reallocation of resources.
Your therapists are doing what we can to change the system. If you’re willing, you can do something, too. No pressure, of course. But if it sounds exhilarating to speak up, and to help tame the beast, then drop me an email and we’ll get together. To chat and post.
(34 days to go. My countdown has been a little off. I’ve recalibrated using May 30, my actual last day at Kaiser.)
From the Therapy Offices to the Streets, Together
Posted on April 29, 2014 by weisskoff
When I returned from vacation yesterday, I was surprised to find out that my therapist colleagues in Santa Rosa are interested in going on strike! Last week, it seemed that everyone wanted to wait and see how the DMHC hearing rolls out before committing to walking off the job.
But the daily pressure of meeting with clients and, no matter how serious their symptoms and issues, not having the time to see them again, has taken its toll. Santa Rosa therapists are ready to add our voices to the chorus.
Just as an aside… There are class action suits in process for Kaiser members and their families who have suffered as a result of inadequate mental health services. (See for example: http://www.sl-employmentlaw.com/files/first_amended_complaint_-_futterman_et_al._v._kaiser_foundation_health_plan__et_al..pdf) How about a lawsuit that defines Kaiser therapists as a class, arguing that putting therapists in front of clients in need of help, but not giving the therapists the opportunity to treat is damaging to the therapists? Just another tactic to bring the facts to light and put pressure on Kaiser to change.
Back to the strike. There are elements of the Oakland strike that we want to emulate, and aspects we can enhance. In Oakland, therapists drafted a list of items they wanted to see addressed by administration by Wednesday, April 23, in order to avoid their strike. When the items were unaddressed by the drop dead date, they followed through with their threat. This left them in the excellent position. They can threaten more strikes over specific issues and Kaiser will have to start bringing the costs of these strikes into their analysis.
One of the chief costs of a strike, from the corporation’s perspective, which I think Oakland did not get to fully capitalize on, is media coverage of the event. I saw nothing in the national press. And even our most liberal local radio station, KPFA in Berkeley, ended their report with the voice of Kaiser’s Northern California Psychiatry Chief who framed therapists’ efforts as strictly a labor dispute. In essence, he said, there are no actual clinical care issues at stake, only problems with our lapsed contract.
So, as we consider our game plan in Santa Rosa, we need to find a way to broadcast only the kinds of facts that any journalist would be curious about and could directly follow up upon to our advantage. For example, if we present the fact that no matter how in pain a Kaiser member is they don’t get to see their individual therapist for between one and two months, the obvious follow-up to a Kaiser spokesperson would be, “Is that true?” What we want to avoid is messaging something too vague, like, “Kaiser is providing substandard and dangerous care for people with mental illness.” Though true, Kaiser’s response to this allegation has been and will be: “No we’re not. We have never put our members at risk.”
And, I’ve said it before, we need to get the voice of consumers out there, loud and clear.
In my last blog posting I put out the offer to get mental health clients more involved in a public way using this website. I have already received several responses from people ready to go public. It would be very powerful on the day of the strike to get a therapist and client pair in the studio at KQED to talk over the problems we are facing as a team.
Because that’s what we are, a team. We are in alliance with our clients in the therapy office. It makes sense we’d be a team outside as well.
(32 days to go.)
Thank you, Gina!!!
Posted on April 30, 2012 by weisskoff
I got a very exciting call last night from Gina, the mom of a young man with Obsessive Compulsive Disorder. He has been under the care of a variety of systems of the years, including Kaiser Psychiatry. On his behalf, and on behalf of all Kaiser mental health clients with parity diagnoses who haven’t been receiving adequate treatment, she’s launched a class action lawsuit. You can read about it on: http://www.courthousenews.com/2014/03/31/66628.htm
A lawyer herself, Gina, sought out Gianelli and Morris, the law firm that sued Kaiser to provide treatment for Pervasive Developmental Disorders (PDD), including autism. The result of that suit, settled out of court last summer, was two-fold. Kaiser created a $9.3 million fund to reimburse out-of-pocket expenses the clients had incurred between 2004 and 2012, paying for the services Kaiser had not been providing. (!) The second outcome was that Kaiser agreed to start providing adequate services to this client population in its outpatient clinics. (!!) In the Santa Rosa clinic we now have a PDD specialist who was hired last year as a result of this settlement.
I found a good summary of the PDD lawsuit on an autism advocacy website: http://www.autismspeaks.org/advocacy/advocacy-news/kaiser-reimburse-ca-families-93-million-aba-speech.
The class action suit I reported on yesterday seems to be focusing on negative outcomes, e.g. suicides. As I’ve said before, it’s difficult to prove that bad outcomes are the result of either the kind of care provided or the lack of care. The class in that class action is smaller (people with bad outcomes) and the case is tougher to make.
But Gina’s class action focuses on the lack of services, not the result of that lack. If Gianelli and Morris follow the same formula they used in the PDD case, they need only provide a little bit of evidence that Kaiser is not treating OCD (and major depression and panic disorder and the remaining parity diagnoses) to leverage Kaiser into paying for the therapy that our clients have been going to community practitioners over the years to treat. And to start providing the care people with parity diagnoses are entitled to under the law.
I think it’s realistic to believe that Gina’s lawsuit, on its own, has a significant chance of forcing Kaiser to make the changes we’ve all been clamoring for. Between class action lawsuits and the Department of Managed Care clamping down, Kaiser is getting hit in the only place that matters to this kind of corporation.
So you can see why I found her phone call so exciting.
(31 days to go.)
Now It’s Personal
Posted on May 2, 2014 by weisskoff
A colleague of mine brought to my attention one of the many barriers to implementing change in our huge, complex system. There’s a lack of personal responsibility for the decisions made at the clinic level; local leaders claim they are just following orders from above. So, for example, when the Department of Managed Health Care (DMHC) noticed last year that our clinic had been concealing actual wait times for first appointments through waitlists, instead of heads rolling, everyone stayed in place. Our clinic managers, I suppose, claimed they were following one of many protocols authorized from far upstream. . . so they had no personal responsibility. Knowing that they will always be protected in this way stops our local leaders from promoting the kinds of changes necessary if we are to have more than the veneer of care.
In an effort to hold our local leadership responsible for the catastrophe of our current system, I sent the following letter to the people identified as in charge of quality control. And published it here.
May 2, 2014
Sheila Clancy, Director of Psychiatry
John Mackey, MD, Chief of Psychiatry
Ginger Hofmann, MD, Quality Chief of Psychiatry
Monica Minguillon MD, APIC for Quality and Risk
Kathy Boyd, AMGA
Guy Chicoine, Medical Group Administer
Daniel P Garcia, Chief Compliance Officer Kaiser
Dear Quality Assurance Officers:
As many of you know, I am a therapist on the adult team of the Psychiatry Department in Santa Rosa. I am writing because I was instructed by Guy Chicoine on 4/24/14 to direct any “quality and access concerns at the individual level” to all of you. I would appreciate it if you forwarded this message to Daniel P Garcia, Chief Compliance Officer for the Plan, as I cannot locate a usable email address for him within Lotus Notes. And these quality concerns are so widespread and grave that he needs to be involved for a system-wide repair.
I am leaving Kaiser at the end of the month and am determined to promote as much positive change for our mentally ill Kaiser members as possible before I go. If you haven’t already, please read about these efforts at 90daystochange.com. As fair warning, this letter and your responses, if any, may become part of that public website. A good many of our client population receive federal dollars through Medicare and MediCal. In your roles as Quality Assurance officers, you are each responsible, personally, for the quality of care these publicly-funded clients receive.
This week I co-facilitated the first session of two of our excellent skills groups: Mindful Mood Management, which is our department’s primary referral for people with depression, and DBT Basics Overview, which is our primary referral for people with a variety of self-destructive coping patterns.
On Tuesday, April 29, only 10 out of 23 people scheduled showed up to our DBT Overview group. Of those who did not show, 6 had a diagnosis of Major Depression Recurrent, 2 had a diagnosis of Bulimia, and 1 had a diagnosis of Panic disorder — all parity diagnoses in California.
On Wednesday, April 30, only 14 out of 24 clients showed up for the first session of Mindful Mood Management. Of those who did not show up, 8 out of 10 currently carry a diagnosis of Major Depression, Recurrent, a parity diagnosis.
These are the individual clients I am writing to you about, the 17 people with parity diagnoses who did not show to my two groups this week. In particular, the 14 with Major Depression, Recurrent should be of most concern to all of you, as they are at the highest risk of suicide. These 17 are obviously just the tip of an enormously problematic iceberg.
In our department, and in Psychiatry Departments throughout the State, Kaiser has a long-standing strategy of providing very little individual psychotherapy. That “very little” has dropped to almost nothing since January 1, 2014. On average, for the last several months that I have personally been tracking it, the wait time between individual therapy appointments has been at least 4 weeks. For Spanish-speaking clients, it is almost twice as long.
In the absence of a solid foundation of meeting with a therapist one-on-one, the chances that clients will follow through with group therapy are, as shown above, unlikely. (What I reported above is the drop out rate for the first session of these groups only. Without the support of individual therapy visits, many more clients will drop out over the course of the group.) When these clients drop out of treatment, they are at great risk for bad outcomes like hospitalization and suicide. But even if they don’t kill themselves, their misery — the symptoms that define their mental illness — continues unnecessarily.
As you know, parity laws require that Kaiser adequately treat people with Major Depression, Panic Disorder, Bulimia, and other conditions. Without funding individual therapy, Kaiser is not obeying even the spirit of these laws.
For the sake of the many, many clients we see struggling with mental illness, I hope you will develop a plan to remedy the deficits as soon as possible.
Andy Weisskoff, LCSW IBHS-NUHW Steward
(28 days to go.)
Posted on May 6, 2014
I’ve left my fair share of jobs. Leaving this one’s excruciating.
For the past month I’ve been saying goodbye to clients, some of whom I’ve known for seven years or more. In previous jobs, leaving hasn’t felt like an abandonment. I was passing my clients into the good hands of trusted colleagues. Though my colleagues at Kaiser have similarly trustworthy hands, theirs are tied in knots, limited by the corporation’s singular focus on making money. These days, in psychiatry departments throughout California, this focus translates to the one goal of meeting initial access regulations to beat the fines from the Department of Managed Health Care (DMHC). Incidentally, last week it was announced that the hearing in Oakland — Kaiser protesting the $4 million in fines — has been postponed from May until September. I take this as good news, that all the public attention and pressure to provide actual care is making it harder for Kaiser to bully its way past the systems designed to check their avarice.
On my way out the door, I’ve been transferring my clients with an eye toward finding them the most accessible therapists. These are the ones who have been hired the most recently. Unfortunately, they are also the ones I know least. While they do seem kind and competent and ethical, I don’t yet know them. Turning over my clients’ care to people I don’t know is part of what’s difficult. The other part is knowing that a new hire’s availability is short-lived. Within a year or so, a newbie will be just as backed up as old-timers. And my former clients will be fighting to be seen by them, just as they had to fight to see me. Until they give up.
In the last week, my direct supervisor has come to me three times, always with the same question. How many of the people that you’re still seeing are going to need a new therapist? This, of course, because of initial access. Every transfer takes up a slot that could otherwise go to a new client intake. He needs the information so he can strategize with my other bosses about how to absorb the loss of intake appointments. To avoid, yes, more fines from the DMHC for not meeting initial access.
Meanwhile, one of my colleagues is considering taking on a manager position on the Child and Family Team. For him the most daunting condition of employment is that he’ll have to give up seeing clients face to face. Within the last year or so, the structure for managers has shifted dramatically from having 20% or so of their time devoted to direct service hours, to having no face to face time in their schedules. This shift came when our managers’ bosses realized that manager-clinicians, people who provided therapy to the same clients as line staff, were confused about the bottom line. Was it patient care or corporate care? Whose side are they on?
When managers have to face the same dilemmas we do, and I mean be face to face with them, they are much more likely to be sympathetic to client needs. And to our anxieties as therapists when these needs aren’t being met. That’s not where you want your managers’ sympathies to lie if you want them to curtail basic services to meet a single metric. My previous supervisor, Maryellen Curran, was a manager-clinician. If I had concerns about my clients we would talk about them, as two clinicians respectful of each other’s work. We had similar curiosities about treatments. She shared my concerns about client care. When Maryellen left, I got a boss.
My friend, the one who’s considering the manager position, is trying to negotiate keeping some face to face time with clients. Will our bosses let him get away with it? For the sake of the children and families being served by the Child and Family Team, I hope so.
(24 days to go)
Posted on May 7, 2014
I sent two emails in the past week to the people in charge of compliance and quality issues for Kaiser’s Santa Rosa Medical Center. (See the post “Now It’s Personal”) I was hoping through these emails to dislodge our local leadership from their comfort zones. Perhaps, I hoped, if they were a little more uncomfortable they might come closer to addressing the unconscionable deficits in mental health care services provided by the Psychiatry Department.
To put in writing that you, Dr. Monica Minguillon, (who has the authority and responsibility to address issues of quality care throughout the medical center), and to put in writing that you, Dr. John Mackey, (who, as department chief, has the responsibility for all that happens within your department), are being notified about some serious flaws in how these systems take care of people with mental illness. . . Well, with any luck, these reminders posted in public on a website will generate an itchy concern about personal liability, an accountability for the many disasters past, present, and future due to a lack of actual oversight.
Yesterday I did my best to drive that concern about personal liability home.
I was following up on the people who didn’t come to my groups last week. Among this cohort I found two who seemed at great risk for deterioration of their mental health conditions and who carried the parity diagnosis of Major Depression, Recurrent. One had a therapist who has an average of seven weeks between appointments. The other doesn’t have a therapist at all, but if assigned one would be waiting at least four weeks between appointments.
For each of these two, I put a note in their electronic chart. I pointed these facts out in the note and said, “Without the support of a primary therapist who this patient can see on a frequent basis, it is not surprising that she did not come to group.” And, “This patient is at risk for deterioration of her mental health condition, for psychiatric hospitalization, suicide, and the unneccessary continuation of emotional suffering because she does not have the support of an individual therapist she can see for her mental health parity condition.” And routed this chart note to the four clinicians identified as in charge of quality: Kirk Pappas, MD, Physician-in Chief, John Mackey, MD, Chief of Psychiatry, Ginger Hofmann, Quality Chief of Psychiatry, and Monica Minguillon MD, APIC for Quality and Risk. (I don’t know what APIC stands for, but it sounds official.)
By law, once an electronic chart note is entered, it’s not going anywhere. It can be addended, altered, but the original versions should always be available at the click of the “Previous Versions” button. Deleting these notes is a big, legal no-no. And now attached to these virtually permanent chart notes are their routing histories to the people in charge of addressing patient risk.
I also felt a responsibility to add a note to the medical record of a man who killed himself on my watch.
In that note I reviewed his experiences in our department and then added, “I believe if he had seen me weekly for the first month of his care, the outcome may well have been different. I am writing this chart note years after his death because the same conditions exist now in our department that did when he killed himself, conditions that if left unaddresed may lead to more preventable suicides.” And, “Specifically, on average, a patient will wait more than four weeks between individual appointments with a primary therapist regardless of severity of diagnosis or symptoms. They may be referred to urgent care services in between these visits. But the fundamental tool used to address mental illness – face to face contact with their primary mental health provider – is denied them.”
I also commented on the lack of any sort of quality review of his case: “I see no record of his cause of death in his chart.” And, “I also see no indication in the chart that any quality assurance process was instigated to make sure that his death was neither the result of clinician error nor system error.”
I routed this note to Doctors Pappas, Mackey, Hofmann and Minguillon.
Let’s see how itchy it makes them.
(23 days to go.)
Posted on May 8, 2014
My Latin teacher in high school, Shirley Hodes, told us about a Roman saying. This was some time ago, so I’m sure I’m remembering it only half-right. She said, “If you stumble on your doorstop on the way to work, you should turn around and spend the day in bed.” Oddly enough, I tripped on my way down the stairs this morning. I guess those Romans knew what they were talking about!
When I got to work, I tried signing on to my computer. It announced to me that I was locked out and would need to speak with an administrator to log on. I assumed there would be some information about this lock-out on my voicemail, but, same deal. I couldn’t get into my voicemail either.
So, I reasoned, THE DAY has finally come. It was still kind of creepy. Like in a film noir when the villain snips the telephone wires, leaving the heroine cut off from the outside world, and circles the building rubbing his hands together.
A few minutes later the Chief of Psychiatry, John Mackey, invited me into his office where Guy Chicione, lead administrator for the Santa Rosa Medical Center and another man, someone who gets called in, I guess, when people are being fired, were seated.
Guy told me that my resignation was being accepted as of today. I don’t want to quote him, but it was some kind of doublespeak like that. Not “fired,” not “let go.” They were just forcing me to leave the building never to return and didn’t have a protocol with attendent language to fit that situation.
Guy told me that my remaining patients were being taken care of. I asked if he could say why I was being asked to leave before the scheduled May 30 date and he repeated what he had said, that thing about my resignation being accepted as of today. I was told I would be paid for the time between now and May 30. I was told I need to turn in my key and badge immediately and not to return to the department except to pick up my belongings, at a time to be scheduled in the near future with my supervisor.
I was permitted a moment to take some personal belongings from my office, accompanied by the mystery man from the Medical Center. I took down the artwork from my walls and packed up my EMDR light bar, much to the chagrin of the mystery man who wanted to get back to his real work. Dr. Mackey emerged at my office and offered to help carry my prints to my car. The mystery man reluctantly helped, too. No security was involved, but the phrase “escorted off the premises” comes to mind anyway.
I sat in the parking lot more than a little stunned. I had the in-shock feeling that I’ve only experienced twice in my life. Both times were at my Kaiser job when I found out that clients I had been working with had committed suicide.
At home, I spoke with my friends at the National Union of Healthcare Workers (NUHW) and got lots of support and encouragement. They were wondering, Why now? The most logical explanation is that my most recent action, charting about patient risk and forwarding these notes to the adminstrators responsible for managing risk, was a tipping point in the Kaiser machine’s cost/benefit analysis, the pros and cons of keeping me around versus booting me out.
I’m tremendously grateful and actually proud that, in the end, I got to write a closing chart note about my client who killed himself. I feel I can close that chapter of my life now. His death has haunted me for some time, and writing that note helps me feel that I’ve done what I can do to speak the truth around his poor care.
Just this morning, right before tripping on my doorstep, I had been debating whether or not I could afford to take a two week vacation, after the ninety days were through and before I start my private practice. Now I can take three!
Even though the clock has been fast-forwarded and there are suddenly 0 days to go, don’t worry. There’s plenty more of this story yet to unfold. I wouldn’t be surprised if the real excitement is just beginning.
Thanks for all the support everyone. I’m not lying when I say I am A-OK!!
Posted on May 9, 2014
When I came out of my stupor this morning, after a really bad night’s sleep, I started worrying about my clients who had been dumped mid-stream. Yesterday, Guy Chicione and John Mackey told me they had “taken care” of those remaining clients, the ones scheduled through the end of the month but I won’t be seeing anymore because I’ve been relieved of duty. Most of these people will be fine, I anticipate. Shocked, perhaps. Maybe a little miffed about being denied a proper termination session. But otherwise OK.
There are three, however, that come to mind as being at great risk for getting worse because of the rupture in treatment. I was using EMDR with all three, addressing their experiences of childhood abuse, and had timed our work together so they could come to some closure by the end of the month. I cannot overstate the case that in EMDR it is essential to finish what you start, and to finish with the same therapist you have come to trust.
Knowing that these three people are only midway along, struggling to create a sense of safety in the presence of the memories activated in our first sessions, is really upsetting. If you’re curious about why I’m so concerned, you can read some more about what happens during EMDR on a page from my website.
I emailed my former supervisor and asked him if he’d be willing to call up these three clients and give them my private practice website and my phone number. I let him know that I would like to offer my services to these three for free through the end of the month, the timeframe we had set up in the first place that felt fairly safe. He wrote back and said he could let them know about my website, but that was it. Nothing about the free services. I don’t think they’re going to understand what I’m offering if he only says that I’ve got a private practice.
On Monday I’ll call the psychiatrists also working with these three and pitch my case. All three clients have been suicidal in the past. There’s plenty of risk to be averted and not much to lose by allowing them to finish up with me for free. (I’m still on Kaiser’s dime, after all. It’s not like I was fired!) But by supporting this plan they will be admitting that Kaiser has created yet more liability when they pulled an EMDR therapist off line in media res.
They must have thought I had an arsenal of smoking guns up my sleeve, to put themselves at this new risk. It’s really not going to play well in the press:
“Why exactly did you relieve him of his duties in the middle of this delicate therapeutic work?”
(Day 1 of my vacation.)
Posted on May 11, 2014
It didn’t take me long to realize what I need to do next. Since I’m paid through the end of the month by Kaiser, I need to offer to see all the clients who were denied the conclusion of EMDR sessions and termination sessions in my new private practice office. I posted the following note on my private practice website, andyweisskoff.com:
“Kaiser patients: If you were scheduled to meet with me sometime in May, then I would like to honor that commitment and meet with you in my new office for no additional charge. Kaiser is paying me through the end of the month, so your fees, as far as I’m concerned, are already taken care of. And you won’t have to pay a co-payment! So, please call me to reschedule within May.”
I’m also pursuing with my former supervisors getting this message out specifically to the three EMDR clients I wrote about in the previous post, the ones in the midst of intensive remembering of past trauma.
Because it’s just flat out wrong to abandon people like this.
A Classy Action
Posted on May 13, 2014
In the parking lot at Armstrong Woods I found $40, two folded together twenties. My initial plan was to donate twenty to the State Park and buy twenty lottery tickets.
Then I took my hike and put the following pieces together.
As predicted, Kaiser made a ton of money in the first few months implementing the Affordable Care Act, by inviting thousands of new customers onto their rolls and not staffing up to provide for their care. See http://www.bizjournals.com/sanfrancisco/blog/2014/05/kaiser-permanente-q1-profits-kathy-lancaster.html for the staggering level of profits they made in the first quarter alone.
What has become clear to me through this process of quitting and blogging is that nothing is going to change the course of a monster corporation like Kaiser other than threatening its bottom line.
Bad outcomes, like suicide or hospitalization, are dangerous liabilities to individual practitioners. But to Kaiser, to this point, bad outcomes are an acceptable risk. In mental health, Kaiser expects a certain number of law suits to be initiated by family members of suicides. The cost of paying out these individual claims is cheaper than paying for the adequate staffing that would defuse the malpractice claims. The result of these individual settlements is that family members are sworn to secrecy about flaws in the system that led to the suicide, and the corporation continues with business as usual.
See my post “Thank You, Gina” for an alternative to individual lawsuits — the class action suit, and its potential to generate system-wide change. In class action lawsuits, the class, when successful, gets to define the conditions for settlement. In the case of last year’s Autism lawsuit, the conditions for settlement included: (1) Kaiser had to reimburse out of pocket treatment costs incurred to this point by family members who sought services outside Kaiser and (2) Kaiser had to start providing the services they were supposed to have been providing in the first place.
Gina, mom of an OCD client, created another class action suit on behalf of Kaiser families who had paid out of pocket expenses for parity mental illnesses other than Autism. She’s hoping for the same two outcomes: to reimburse costs incurred to this point, and to force the system to change what it is currently providing.
So, I got to thinking. What kind of class action law suit can therapists create that would cost Kaiser enough money to make them consider adequate staffing versus paying court settlements?
Here I am leaving Kaiser because the structure of the Psychiatry Department didn’t allow me to provide the care that my clients needed to improve. I know from personal emails and blog comments that other therapists have left Kaiser for similar reasons. Hey, wait a minute, that’s a class!
But don’t we need damages to be defined as a class?
Up until about a year ago, I saw myself staying at Kaiser through retirement age. That would be somewhere between 62 and 65, right? I’m about to turn 49 in a few days. So I’m losing at least 13 years of Kaiser’s fabulous wages and benefits, (Health insurance alone is going to cost me and my wife $1000/month.) Any year that I make less than what Kaiser would have paid me might constitute damages. I suppose I haven’t been damaged yet. Starting in June I will be. And there are many other therapists out there who have left Kaiser over the years who I bet are making less in private practice than with their former employer.
Why might Kaiser be considered liable for these damages? I’m not a lawyer, but I wonder if a law firm can make a case for Kaiser being responsible for:
(1) Creating and maintaining an environment in which therapists are unable to see clients at intervals appropriate for their improvement through therapy, and,
(2) Creating and maintaining an environment in which suicides are not addressed in a manner that ensures, to the best of the institution’s ability, the prevention of future suicides.
I found it unethical to continue working under those conditions. And I bet some of my colleagues who left felt the same.
I’m going to contact the law firm that Gina is working with. I bet they’ll be excited to represent former Kaiser therapists, too. I’m also inviting (right here, right now) any therapist who has left Kaiser for ethical reasons to contact me at: LCSWAndy@gmail.com. Let’s be a class!
At the end of my hike, I put both twenties into the donation slot by the park entrance. I did that because that was the right thing to do.
(17 days to go.)
Never Can Say Goodbye
Posted on May 17, 2014
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.)
Talking to Martin
Posted on May 19, 2014
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.)
Posted by Weisskoff May 23, 2014
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 didn’t tell him it the date was fine only 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.)
Posted by Weisskoff May 28, 2014
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.
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!
(2 days to go.)
So Long! Farewell!
Posted May 30, 2014
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 on 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 previous 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 alreadymay have become), 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 (givers of endless ataboys), 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), Tim Carroll (predecessor as shop steward and ongoing confidante), my many therapist, receptionist, nurse, nursing 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.)