A Game So Nice I’ll Play it Twice

Posted on September 25, 2014

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

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

On September 9, 2014, moments before they were slated to argue their case in front of an administrative law judge in Oakland, Kaiser dropped their appeal of the Department of Managed Health Care’s $4 million fine. (The fine, if you recall, was levied for delaying access to initial mental health appointments and for discouraging members from seeking services.) Just as remarkably, Kaiser has begun to develop protocols to subcontract the overflow of psychiatry department intakes to a behavioral managed health care group, ValueOptions.

These are incredible developments! Kaiser lawyers, it seems, knew they couldn’t prove Kaiser mental health administrators had responded to the DMHC’s allegations sufficiently or quickly enough, and told Kaiser executives not to fight the fines in court. And, by subcontracting mental health services to ValueOptions, Kaiser has admitted that they are unable to do the job the DMHC is mandating without hiring more help. They are admitting that they are, in fact, understaffed. Which is what therapists have been arguing  for three years now.

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

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

(90 days (or so) to go.)

 

Let’s Talk Medicare Fraud

Posted on October 15, 2014

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

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

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

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

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

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

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

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

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

If that’s not fraud, what is?

(76 days to go.)

 

STRIKE!

Posted on October 27, 2014

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

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

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

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

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

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

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

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

(64 days to go.)

 

Doctors v. Lawyers

Posted on October 19, 2014

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

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

Here’s what I wrote:

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

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

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

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

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

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

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

(72 days to go.)

 

Taking it to the Feds

Posted on November 13, 2014

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

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

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

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

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

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

(47 days to go.)

 

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

Posted on November 17, 2014

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

Hi Belinda,

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

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

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

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

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

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

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

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

Andy

(43 days to go.)

 

Medicare Refresh

Posted on November 22, 2014

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

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

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

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

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

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

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

Markedly Poor Access to Primary Individual Therapists

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

Over-reliance on Group Programs

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

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

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

(38 days to go.)

 

A Quality Complaint

Posted on November 28, 2014

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

I just emailed the following complaint to k…

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

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

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

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

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

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

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

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

(32 days to go.)

 

Yanking Up the Chain

Posted on December 1, 2014

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

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

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

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

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

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

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

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

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

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

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

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

Sincerely,

Andy Weisskoff, Licensed Clinical Social Worker
LCS -20126

(29 days to go.)

 

Dear Mr. President

Posted on December 8, 2014

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

Dear President Obama,

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

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

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

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

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

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

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

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

With Plenty of Admiration,

Andy Weisskoff, Licensed Clinical Social Worker

(22 days to go.)

 

Here Fishing

Posted on December 19, 2014

I know I can’t, in a letter, convince politicians to prioritize the cause of parity mental health care. A politician either has the issue on their radar and embraces it or they don’t. By writing senators and presidents (well, one president) I’ve been fishing for collaborators, advertising that I’m available to participate in the discussion, and hoping someone influential bites.

A couple of months ago my friend Andy Raskin wondered out loud why Kaiser hadn’t tried to hire me as a consultant. It would be good PR, he thought. I didn’t give it much thought at the time, imagining Kaiser executives laughing their heads off at the suggestion. Ironically it was at Kaiser that I learned and then taught the principles of assertiveness, including: You don’t know how another person will respond until you ask directly. So, since we won’t know until I ask, and since I really do think it would be a productive collaboration, and since he might see business advantages to the arrangement, I sent the following message by email and snail mail to the CEO of Kaiser Permanente, Bernard Tyson.

Dear Mr. Tyson,

I am a former employee of the Santa Rosa Medical Center and author of 90 Days to Change, a website providing advocacy for those members receiving behavioral health within the Kaiser model. I’m writing with a sincere offer to help you restructure Kaiser’s mental health services. As you know, TPMG stands on the brink of a series of prolonged and potentially damaging strikes by Kaiser therapists and nurses. I believe you can do some proactive damage control by (1) declaring Kaiser’s intent to address the long waits between individual psychotherapy appointments and (2) hiring me as a consultant to help restructure. In addition to improving public relations in the face of strikes, by restructuring, your corporation may avoid future malpractice lawsuits, class action lawsuits (from members and therapists), future fines from the Department of Managed Health Care (DMHC) and the Centers for Medicare and Medicaid, as well as other possible consequences like loss of membership.

The new model of care I recommend builds on what has started to emerge in response to the DMHC fines — a triage system that separates conditions with high service needs from those with low service needs and sends clients to either contracted therapists for low needs or to in-house therapists for high needs. Here’s what’s missing in this approach. For both tracks, the therapists need the same level of authority as primary care physicians (pcps) have for “physical” conditions – the authority to diagnose, treat, and refer to other components within the system as needed. Unlike pcps, psychotherapists treat the vast majority of conditions themselves, in a series of (relatively) long visits, without referral to specialists like physical therapists. Therapists must have the capacity in their schedules to meet with their clients for frequent (often weekly or twice weekly) visits. As is currently true for pcps, systems will need to be put in place to identify therapist availability and to close or open psychotherapist panels as needed to maintain access to these treaters. While Kaiser’s psychoeducational groups are an essential component of care, therapists need the authority to refer or not to refer members to groups according to each member’s ability to benefit from them. The current model of care, with severe limitations on individual therapy time, means that in most cases groups are the only offering.

To this point the greatest stumbling blocks to implementing this new model of care are the challenges of specifying the conditions Kaiser treats, standardizing procedures to identify members with these conditions, developing treatment standards for each condition, and clarifying when offers of treatment will end. There are no doubt a series of legal roadblocks to declaring which mental health conditions an HMO will treat and how they will treat them, but these must be hashed out in order to provide adequate services to the people in need. Not all mental health conditions are treatable and not all treatments work for everybody. Kaiser members, their families, and the larger public are sympathetic to these facts. Just as most Americans have accepted that HMOs don’t provide every available treatment for every medical condition, I believe most will accept limits on mental health treatment … if these limits are the result of a transparent analysis.

I am quite interested in collaborating. I hope you will accept my offer and we can meet to discuss a future working arrangement. You can phone me at (707) 799-4125 or write me at LCSWAndy@gmail.com.

Sincerely,

Andy Weisskoff, LCSW

(11 days to go.)

 

The Prize Within Reach

Posted on December 29, 2014

In the last ninety days I’ve put offers out to politicians, (hoping they might collaborate with me to change healthcare regulations), to regulatory agencies, (encouraging them to enforce the regs already on the books), and even to the CEO of Kaiser, (asking if he’d let me help restructure behavioral health services throughout Kaiser). I haven’t gotten any direct response to these offers yet. Even though these offers are sincere, I won’t hold my breath. In the next week, I’ll consolidate the blog entries for the last three months under the heading, “The Second 90 days – Reader’s edition,” and consider this phase of advocacy work done.

I’ve had emails and voicemails over the last ten months (since I started blogging here) from Kaiser mental health clients and their family members, from Kaiser therapists, and from Kaiser physicians, all encouraging me to keep this website active indefinitely. It has become a credible source of information and a source of hope to those struggling to improve the system. So, for the foreseeable future, I plan to leave “90 Days to Change” open. I’ll convert the blog area to a forum for stories from therapists and clients to provide up to date information as changes emerge. It is essential that we continue to counter Kaiser’s propaganda (which claims that adequate changes have already been made) with real time data about what’s really going on in clinics and emergency rooms throughout California.

Initially, the power of this blog came from the unique position I was in while preparing to leave my job. Kaiser could not fire me because I was resigning, and they couldn’t threaten to withhold my retirement benefits, since I hadn’t been on the job long enough to earn a pension or medical benefits. This unique position left me free to speak up. Kaiser clients and therapists still in the system, however, are kept silent by fear of retaliation. I hope that “90 Days to Change” will continue to be a safe space for protest, a place where like-minded clients and clinicians can commiserate without endangering their jobs or the healthcare services they receive.

I’m starting a new job in the new year with a non-profit public health clinic a stone’s throw from my home. (I know! No commute!) My private practice is growing nicely. But not nicely enough to pay the bills. And, as the bumper sticker says: I owe, I owe, so off to work I go. I still plan on joining my colleagues on the picket lines in January 2015. I’ll edit and publish new stories from therapists and clients on the front lines of this debate using this blogsite. And I’ll continue to be available to politicians, other lawyers, and Kaiser executives should any of these parties seek out my help. But otherwise, I’ll consider my Kaiser career over.

Thanks, everybody, for your enthusiasm over the last (almost) year. I’m proud and excited beyond all expectation about what we’ve set in motion. Look for the revamped “90 Days to Change” early in January 2015. And continue to support the efforts of the NUHW’s members as they begin their strike on January 12.

The battle has begun in earnest. Onward and upward all!