Editor’s word: Kaiser Health News is an editorially impartial program of the Kaiser Family Foundation that isn’t affiliated with Kaiser Permanente.
OAKLAND, Calif. — After years of state sanctions and fines, Kaiser Permanente claims it has gone a great distance towards bettering its psychological well being care. The nationwide managed-care big — California’s largest insurer with 9 million members — touts greater than 1,200 therapist hires since 2016, improved affected person entry to appointments and an expanded coaching program for psychological well being professionals. Regulators at California’s Department of Managed Health Care report that Kaiser is assembly the benchmarks specified by a 2017 settlement agreement that resulted from two years of negotiations.
But interviews with dozens of Kaiser Permanente therapists, sufferers and business specialists paint a extra troubling image of superficial good points that look good on paper however don’t translate into simpler and accessible care. Many Kaiser sufferers nonetheless battle to entry ongoing remedy, typically ready two months between remedy classes.
Kaiser therapists say that the HMO has found out sport the system arrange by California regulators to measure progress with out meaningfully bettering care. They describe a mannequin that depends on perfunctory consumption interviews, carried out by telephone from name facilities, to point out improved response occasions for sufferers searching for an preliminary appointment, however then fails to comply with via with well timed or common follow-up care.
“The initial intake isn’t starting treatment. It just means the patient has to explain their experience multiple times,” stated Kirstin Quinn Siegel, a licensed marriage and household therapist at Kaiser’s Richmond clinic. “It’s not a way to improve mental health services. It’s a way to improve their numbers.”
Such allegations are central to a five-day walkout deliberate this week involving hundreds of Kaiser’s psychological well being professionals, who hit picket strains Monday demanding extra time for administrative duties, larger wages and shorter wait occasions for affected person appointments.
Of explicit concern, in line with a number of therapists, is a telehealth program referred to as Connect 2 Care. Patients who name in with a psychological well being subject are provided an appointment, typically that very same day, for an consumption evaluation carried out by telephone with a therapist.
The consumption calls, which final about 30 minutes, depend towards assembly the state’s “timely access” regulation, which requires sufferers be given an preliminary pressing appointment inside 48 hours and a non-urgent appointment inside 10 days. A typical consumption interview sometimes lasts at the very least an hour and is completed in individual by a therapist who will present ongoing remedy, in line with the American Psychological Association. Such visits usually embrace a full medical historical past, a psychological standing analysis, an preliminary analysis and the creation of a remedy plan.
In distinction, Kaiser has opened massive name facilities in Livermore and San Leandro, lined with cubicles the place Connect 2 Care therapists present preliminary intakes by telephone. But sufferers communicate with the Connect 2 Care therapist solely as soon as. To ebook a follow-up appointment, they typically wait 4 to eight weeks to see a therapist in one who will present ongoing care. When they lastly get in to see somebody, stated Siegel and others, the affected person tells his story once more, and the brand new therapist has to do one other evaluation. Many sufferers report ready months between every subsequent appointment.
Kaiser officers, when touting enhancements of their psychological well being care, word the system met the state’s well timed entry metric greater than 90% of the time in 2019. But therapists say packages like Connect 2 Care are extra about savvy record-keeping than good drugs.
Michael Torres, a baby psychologist within the San Leandro clinic, stated relating to ongoing remedy, little has modified within the 17 years he’s labored at Kaiser. His schedule is so packed that he’s in a position to see his sufferers solely each 4 to 6 weeks, even when a baby is experiencing main melancholy and must be seen weekly. “It’s heartbreaking,” he stated. “It only exacerbates conditions, prolongs symptoms, and professionally it’s just unethical.”
Torres additionally has a personal follow, the place he says a few of his Kaiser sufferers select to see him extra continuously by paying out-of-pocket. “You then skew those getting better services to those who can afford it,” he added.
Kenneth Rogers, a Kaiser psychologist within the Sacramento space, stated his choices are both to see his sufferers as soon as each two months or to squeeze them in after hours. “Whatever you’re working on, it’s not fresh in eight weeks. For most patients, you want to be regularly following up,” he stated.
“I tell people if they have serious mental health issues, don’t go with Kaiser,” stated Augie Feder, a therapist who left Kaiser final 12 months and has a personal follow in Berkeley.
While complaints about insufficient psychological well being care stay frustratingly commonplace all through America’s well being care system, Kaiser, headquartered in Oakland, has come underneath explicit scrutiny from California regulators lately, partly as a result of its therapists have been aggressive in documenting considerations.
In 2013, the state Department of Managed Health Care discovered Kaiser was systematically shortchanging sufferers searching for psychological well being remedy in violation of the state’s parity regulation, and levied a $four million wonderful. In 2015, regulators once more cited Kaiser, discovering some patients were waiting months to see a psychiatrist or therapist. In 2017, the state cited Kaiser a third time for persistent issues. This time, the events reached a settlement requiring Kaiser to rent an out of doors advisor for 3 years to enhance entry and oversight.
Since then, the National Union of Healthcare Workers, which represents three,600 Kaiser psychological well being therapists in California — spanning psychologists, marriage and household therapists, social staff and psychiatric nurses — has continued to confront Kaiser for what the union says are ongoing lapses.
“Kaiser is trying to teach to the test,” stated Fred Seavey, analysis director for the union. Still missing sufficient therapists to fulfill affected person demand, he stated, Kaiser — regardless of $79.7 billion of working income in 2018 — makes use of an “austerity model” through which the system rations care by front-loading assets towards preliminary appointments on the expense of ongoing care.
A survey by NUHW of 759 Kaiser therapists in April discovered that 71% stated wait occasions for appointments at their clinics had gotten worse up to now two years; simply four% stated particular person weekly appointments can be found for sufferers who want them. The union has collected greater than 1,300 stories from sufferers who say they’ve been unable to entry sufficient psychological well being care.
In a September letter to the American Psychological Association, Kaiser accused the union of “an ongoing public pressure campaign … to try and pressure Kaiser Permanente management to agree to their financial demands.”
“We‘re doing as much as anyone to get ahead of this national issue,” stated Dr. Don Mordecai, a psychiatrist and Kaiser Permanente’s nationwide chief for psychological well being and wellness. “We’re certainly aware that we have some challenges.” Rates of melancholy, nervousness, suicide and habit have soared throughout the nation lately, and it has been troublesome to fulfill the demand, he stated.
Adding to the issue, Mordecai stated, is a scarcity of psychological well being staff that slows hiring. Kaiser has grown its psychological well being workforce in California by 30% since 2015, however membership has grown 23% over the identical interval, leaving the ratio of sufferers per therapist little modified. The Connect 2 Care program offers sufferers fast entry to a psychological well being skilled, he stated, and surveys present affected person satisfaction is excessive.
Kaiser has launched an initiative to coach 140 therapists every year and allotted $10 million to develop its postgraduate coaching program. Kaiser additionally has contracted with outdoors suppliers, together with Beacon Health Options and Magellan Health, to enhance entry to care.
Mordecai stated a part of the issue is the mindset that every one sufferers with melancholy or nervousness must be in prolonged particular person remedy. “That is dated,” he stated. “We’re not going to have enough providers to do that.” Instead, he argued, many sufferers with reasonable psychological well being considerations must be handled in a major care setting.
In distinction to the union survey, Kaiser spokesman Vincent Staupe stated a overview of return remedy visits discovered that sufferers are being seen in line with therapists’ documented suggestions greater than 84% of the time.
But a number of Kaiser therapists stated the digital information system that helps generate that statistic is deceptive.
“If you say that to any clinician in any Kaiser clinic their jaw will just drop, because it’s just not true,” stated Siegel at Kaiser’s Richmond clinic. “There is almost no clinician that is seeing their patients as often as they would recommend.”
When therapists enter the date of a affected person’s subsequent appointment into the default template for the digital well being information system, for instance, it’s listed underneath “recommended treatment options,” when the date is actually primarily based on appointment availability, stated Siegel.
“The language looks like the therapist is recommending that the patient come back in four, six or eight weeks, which is almost never what a clinician would recommend,” Siegel stated.
Siegel stated therapists in Richmond and elsewhere are inserting their very own language that specifies the frequency of appointments the therapist believes is clinically acceptable (often weekly or biweekly) earlier than writing the date of the “next available return appointment.”
Asked in regards to the concern, Marc Brown, a Kaiser spokesman, stated, “We have numerous templates within the behavioral health record, and they are evolving constantly to make them more useful.” He reiterated that the suggestions are decided and entered into the report “solely by clinicians.”
Patients contacted by KHN described the irritating hurdles of attempting to get assist via Kaiser: calls to therapists to no avail; hours spent on maintain; months of remedy delayed.
Matthew Wasserman stated he was “excited to join Kaiser” when he signed up for protection in January 2019. “I heard the health care was great, but the one thing everyone told me was that the mental health was really bad,” stated Wasserman, 36, who lives in Los Angeles.
Wasserman, who suffers from nervousness, knew that becoming a member of Kaiser meant giving up weekly appointments together with his longtime therapist. He referred to as Kaiser per week after his protection began to discover a new one. Following an preliminary appointment, he was advised the subsequent out there follow-up wasn’t for 3 to 4 months. Instead, somebody from Beacon Health could be in contact.
Wasserman waited greater than per week, however nobody referred to as. He began contacting therapists on Beacon’s on-line listing. Out of the 30 to 40 he referred to as, 5 referred to as again. Three had no openings. The different two had time noon, however he couldn’t miss work.
So, he referred to as Beacon and waited almost two hours on maintain. Two weeks later, he acquired an e mail itemizing three extra suppliers. None returned his calls.
“I have anxiety, so to find time at work to call and go through all my health care information over and over, it was really hard,” Wasserman stated.
It was solely after he filed an official grievance that Kaiser discovered a therapist who may see him on an ongoing foundation — almost 4 months after his preliminary request.
For different sufferers, the results have been extra excessive.
In June 2017, Kevin Dickens of Alameda was depressed, anxious and suicidal. “My wife would come home and find me curled in a ball in the corner,” stated Dickens, 42. His major care physician prescribed Prozac, however Kaiser stated it had no out there remedy appointments.
Instead, he was despatched an inventory of 20 contracted suppliers to name. “It took me two weeks to go through the entire list, getting denied by every single doctor,” he stated. He referred to as Kaiser and was despatched one other 20 names, however once more was unable to get an appointment.
Dickens referred to as a 3rd time and was scheduled with a psychiatrist who had a gap three weeks later, almost 9 weeks after his preliminary request. He went to the appointment, however three days later tried suicide and was hospitalized.
After his launch, Kaiser linked him with a therapist who may see him each six weeks. “I felt I needed every two weeks,” he stated. “But there was nothing I could do.”
The American Psychological Association wouldn’t touch upon Kaiser Permanente’s mannequin. But Lynn Bufka, a senior director on the group, stated each examine she has seen on the effectiveness of remedy relies on appointments occurring at the very least as soon as per week. “So it really does raise the question of whether psychotherapy can be effective if you’re only seeing someone every four or six weeks,” Bufka stated.
Shelley Rouillard, director of the California Department of Managed Health Care, stated her division has not but checked out whether or not sufferers are in a position to entry follow-up appointments and can have extra info on how they’re faring after a future survey. Still, she stated, Kaiser has made enhancements since 2017 and to date has met the benchmarks arrange within the settlement settlement. She wouldn’t share specifics, saying the small print are usually not public.
“That doesn’t mean patients aren’t having trouble getting services,” Rouillard stated. “That’s happening throughout the health care system.”
Access to inexpensive outpatient remedy certainly stays a nationwide downside. A recent report from Milliman, a well being care consulting firm, discovered Americans had been dramatically extra prone to resort to out-of-network suppliers for psychological well being care than for different situations due to insufficient supplier networks.
But given Kaiser’s market dominance in California and its fame as a signature mannequin for built-in care, the system’s critics say the continued shortfalls in psychological well being care are each damaging and unacceptable.
“What I want to ask Kaiser executives is, would you send your loved one to our clinic? Would you want your family member with severe depression or debilitating anxiety or some other mental health condition to be seen once every six or eight weeks?” Siegel stated. “I don’t think they would. I think they would want their loved one to get more treatment than we are able to provide.”