A Flawed Model for Care 

Kaiser Permanente has been held up as a national model for healthcare, but critics contend that it routinely fails to adequately serve patients with mental health problems.

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Following a routine medical survey and subsequent investigation into Kaiser's mental health program, the DMHC, the state's managed healthcare regulatory agency, found in June 2013 that Kaiser's behavioral health services violated California's timely access laws, which limit wait times, protect patients' access to health appointments, and require health maintenance organizations (HMOs) to have adequate numbers of doctors. Specifically, regulators found that Kaiser underreported wait times, did not properly track the availability of doctors, and made patients wait too long between appointments. The agency also found that Kaiser violated state and federal laws by providing misleading education materials that dissuaded patients from seeking services.

Regulators found that Kaiser's internal record-keeping system had discrepancies between its electronic records and a parallel set of paper records, a possible indication that the health giant was attempting to hide lengthy wait times. "The Department's actions are a result of both the seriousness of the deficiencies and the failure of Kaiser to promptly correct them," said DMHC Director Brent Barnhart in a press release announcing the $4 million fine it was levying against Kaiser a year ago. "The Department is taking this action to ensure that Kaiser promptly corrects these deficiencies and provides its patients with the mental healthcare promised to them by their health plan."

Kaiser has disputed the regulators' findings and the financial penalty, with one Kaiser official calling them "unwarranted and excessive." "It is very important to emphasize about the findings given by the DMHC, that there was no issue with quality of mental healthcare we provide that was indicated or found, and there was no issue with access to urgent or emergent care," said Dr. Mason Turner, chief of psychiatry at Kaiser Permanente's San Francisco Medical Center, and assistant director of Mental Health and Chemical Dependency Services for Kaiser Permanente Northern California. In an interview, Turner said that Kaiser has corrected each of the deficiencies found by the DMHC, some before the fine was even handed down. "We look at problems that we have that come up as any system would do, but I think the difference with Kaiser Permanente is that we act quickly and we act decisively to correct those problems," he said.

The DMHC is scheduled to face off next month with Kaiser in an administrative hearing to determine whether or not the fine was warranted.

Kaiser also has objected to the DMHC's requirements for monitoring and reporting appointments under the agency's "Timely Access Regulation," which has been in effect since 2010, and which Kaiser claims "provides no specific guidance." The regulation mandates that the DMHC ensures that health plans abide by state laws requiring plans to provide "non-urgent" appointments for patients to see a mental healthcare provider within ten business days of a request for an appointment.

"The Department has imposed this fine despite Kaiser's continuous efforts to comply with the Department's evolving interpretation of a newly enacted regulation," Kaiser officials said in a prehearing conference statement in April 2014 in advance of the administrative hearing. "This action is premature, the fine is unwarranted, and both represent a manifest abuse of discretion."

But documents submitted by the National Union of Healthcare Workers (NUHW) to the DMHC show that at two East Bay Kaiser hospitals, most mental health patients have to wait a long time for an appointment. A recent report from the NUHW showed that in May 2014, just 39 percent of first-time adult patients in Kaiser Richmond's psychiatry department were seen within the legally required ten days. In that same month at Kaiser Oakland's psychiatry department, only 35 percent of patients received timely appointments.

Another NUHW report found that of nine Southern California medical facilities studied, only one of the centers met timely access standards from June to October 2013 for mental health services, while one-third met the timely access standards less than 50 percent of the time. In December 2013 and January 2014, Oakland Kaiser's psychiatry department's "Crisis Response Team" was so short staffed that hospital management sent more than a dozen messages asking clinicians to volunteer to fill staffing gaps. Included in a package of documents that the NUHW sent to the DMHC earlier this year was an email from the director of neuropsychology of Kaiser San Francisco Medical Center that showed that the hospital was waiting up to twenty weeks before making a phone call to schedule pediatric neuropsychological testing and regular cognitive evaluation. Timely access laws require that health plans offer appointments to see a specialist within fifteen days.

Kaiser's own clinicians complain that their employer's attempts to remedy the problems are disingenuous. Further documents submitted by the NUHW to the DMHC show that Kaiser's Sunset Medical Center, Woodland Hills Medical Center, and Panorama Medical Center in Southern California front-loaded appointments in recent months, getting patients through the door initially but then providing delayed or non-existent follow-up services — a practice Kaiser clinicians have dubbed "rapid access to no care." Those same clinicians reported recent delays of seven weeks between intake and follow-up appointments for therapy for patients with severe mental health disorders, including eating disorders and hallucinations.

"If you have huge waiting times for people needing mental heath services, one of the corollaries of that is that you have to worry that something is going to happen to these people in the meantime," said Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, a behavioral health advocacy group in Washington, DC. "One type of worry is that we're going to have a higher number of people committing suicide."


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