Despite quick fixes, Kaiser Permanente mental health care still lags

Reviewed by James Ives, M.Psych. (Editor)Dec 17 2019

After years of state sanctions and fines, Kaiser Permanente claims it has gone a long way toward improving its mental health care. The national managed-care giant — California's largest insurer with 9 million members — touts more than 1,200 therapist hires since 2016, improved patient access to appointments and an expanded training program for mental health professionals. Regulators at California's Department of Managed Health Care report that Kaiser is meeting the benchmarks laid out in a 2017 settlement agreement that resulted from two years of negotiations.

But interviews with dozens of Kaiser Permanente therapists, patients and industry experts paint a more troubling picture of superficial gains that look good on paper but do not translate into more effective and accessible care. Many Kaiser patients still struggle to access ongoing treatment, often waiting two months between therapy sessions.

Kaiser therapists say that the HMO has figured out how to game the system set up by California regulators to measure progress without meaningfully improving care. They describe a model that relies on perfunctory intake interviews, conducted by phone from call centers, to show improved response times for patients seeking an initial appointment, but then fails to follow through with timely or regular follow-up care.

"The initial intake isn't starting treatment. It just means the patient has to explain their experience multiple times," said Kirstin Quinn Siegel, a licensed marriage and family 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 planned this week involving thousands of Kaiser's mental health professionals, who hit picket lines Monday demanding more time for administrative tasks, higher wages and shorter wait times for patient appointments.

Of particular concern, according to multiple therapists, is a telehealth program called Connect 2 Care. Patients who call in with a mental health issue are offered an appointment, sometimes that same day, for an intake assessment conducted by phone with a therapist.

The intake calls, which last about 30 minutes, count toward meeting the state's "timely access" regulation, which requires patients be given an initial urgent appointment within 48 hours and a non-urgent appointment within 10 days. A standard intake interview typically lasts at least an hour and is done in person by a therapist who will provide ongoing treatment, according to the American Psychological Association. Such visits generally include a full medical history, a mental status evaluation, an initial diagnosis and the creation of a treatment plan.

In contrast, Kaiser has opened large call centers in Livermore and San Leandro, lined with cubicles where Connect 2 Care therapists provide initial intakes by phone. But patients speak with the Connect 2 Care therapist only once. To book a follow-up appointment, they often wait four to eight weeks to see a therapist in person who will provide ongoing care. When they finally get in to see someone, said Siegel and others, the patient tells his story again, and the new therapist has to do another assessment. Many patients report waiting months between each subsequent appointment.

Kaiser officials, when touting improvements in their mental health care, note the system met the state's timely access metric more than 90% of the time in 2019. But therapists say programs like Connect 2 Care are more about savvy record-keeping than good medicine.

Michael Torres, a child psychologist in the San Leandro clinic, said when it comes to ongoing therapy, little has changed in the 17 years he's worked at Kaiser. His schedule is so packed that he is able to see his patients only every four to six weeks, even when a child is experiencing major depression and should be seen weekly. "It's heartbreaking," he said. "It only exacerbates conditions, prolongs symptoms, and professionally it's just unethical."

Torres also has a private practice, where he says some of his Kaiser patients choose to see him more frequently 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 in the Sacramento area, said his options are either to see his patients once every 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 said.

"I tell people if they have serious mental health issues, don't go with Kaiser," said Augie Feder, a therapist who left Kaiser last year and has a private practice in Berkeley.

While complaints about inadequate mental health care remain frustratingly commonplace throughout America's health care system, Kaiser, headquartered in Oakland, has come under particular scrutiny from California regulators in recent years, in part because its therapists have been aggressive in documenting concerns.

In 2013, the state Department of Managed Health Care found Kaiser was systematically shortchanging patients seeking mental health treatment in violation of the state's parity law, and levied a $4 million fine. In 2015, regulators again cited Kaiser, finding some patients were waiting months to see a psychiatrist or therapist. In 2017, the state cited Kaiser a third time for persistent problems. This time, the parties reached a settlement requiring Kaiser to hire an outside consultant for three years to improve access and oversight.

Since then, the National Union of Healthcare Workers, which represents 3,600 Kaiser mental health therapists in California — spanning psychologists, marriage and family therapists, social workers and psychiatric nurses — has continued to confront Kaiser for what the union says are ongoing lapses.

"Kaiser is trying to teach to the test," said Fred Seavey, research director for the union. Still lacking enough therapists to meet patient demand, he said, Kaiser — despite $79.7 billion of operating revenue in 2018 — uses an "austerity model" in which the system rations care by front-loading resources toward initial appointments at the expense of ongoing care.

A survey by NUHW of 759 Kaiser therapists in April found that 71% said wait times for appointments at their clinics had gotten worse in the past two years; just 4% said individual weekly appointments are available for patients who need them. The union has collected more than 1,300 stories from patients who say they have been unable to access adequate mental health 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," said Dr. Don Mordecai, a psychiatrist and Kaiser Permanente's national leader for mental health and wellness. "We're certainly aware that we have some challenges." Rates of depression, anxiety, suicide and addiction have soared across the country in recent years, and it has been difficult to meet the demand, he said.

Adding to the problem, Mordecai said, is a shortage of mental health workers that slows hiring. Kaiser has grown its mental health workforce in California by 30% since 2015, but membership has grown 23% over the same period, leaving the ratio of patients per therapist little changed. The Connect 2 Care program gives patients rapid access to a mental health professional, he said, and surveys show patient satisfaction is high.

Kaiser has launched an initiative to train 140 therapists each year and allocated $10 million to expand its postgraduate training program. Kaiser also has contracted with outside providers, including Beacon Health Options and Magellan Health, to improve access to care.

Mordecai said part of the problem is the mindset that all patients with depression or anxiety should be in extended individual therapy. "That is dated," he said. "We're not going to have enough providers to do that." Instead, he argued, many patients with moderate mental health concerns should be treated in a primary care setting.

In contrast to the union survey, Kaiser spokesman Vincent Staupe said a review of return therapy visits found that patients are being seen according to therapists' documented recommendations more than 84% of the time.

But several Kaiser therapists said the electronic records system that helps generate that statistic is misleading.

"If you say that to any clinician in any Kaiser clinic their jaw will just drop, because it's just not true," said 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 patient's next appointment into the default template for the electronic health records system, for example, it's listed under "recommended treatment options," when the date is really based on appointment availability, said 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 said.

Siegel said therapists in Richmond and elsewhere are inserting their own language that specifies the frequency of appointments the therapist believes is clinically appropriate (usually weekly or biweekly) before writing the date of the "next available return appointment."

Asked about the concern, Marc Brown, a Kaiser spokesman, said, "We have numerous templates within the behavioral health record, and they are evolving constantly to make them more useful." He reiterated that the recommendations are determined and entered into the record "solely by clinicians."

Patients contacted by KHN described the frustrating hurdles of trying to get help through Kaiser: calls to therapists to no avail; hours spent on hold; months of treatment delayed.

Matthew Wasserman said he was "excited to join Kaiser" when he signed up for coverage 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," said Wasserman, 36, who lives in Los Angeles.

Wasserman, who suffers from anxiety, knew that joining Kaiser meant giving up weekly appointments with his longtime therapist. He called Kaiser a week after his coverage started to find a new one. Following an initial appointment, he was told the next available follow-up wasn't for three to four months. Instead, someone from Beacon Health would be in touch.

Wasserman waited more than a week, but no one called. He started contacting therapists on Beacon's online directory. Out of the 30 to 40 he called, five called back. Three had no openings. The other two had time midday, but he couldn't miss work.

So, he called Beacon and waited nearly two hours on hold. Two weeks later, he got an email listing three additional providers. 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 said.

It was only after he filed an official grievance that Kaiser found a therapist who could see him on an ongoing basis — nearly four months after his initial request.

For other patients, the consequences have been more extreme.

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," said Dickens, 42. His primary care doctor prescribed Prozac, but Kaiser said it had no available therapy appointments.

Instead, he was sent a list of 20 contracted providers to call. "It took me two weeks to go through the entire list, getting denied by every single doctor," he said. He called Kaiser and was sent another 20 names, but again was unable to get an appointment.

Dickens called a third time and was scheduled with a psychiatrist who had an opening three weeks later, nearly nine weeks after his initial request. He went to the appointment, but three days later attempted suicide and was hospitalized.

After his release, Kaiser connected him with a therapist who could see him every six weeks. "I felt I needed every two weeks," he said. "But there was nothing I could do."

The American Psychological Association would not comment on Kaiser Permanente's model. But Lynn Bufka, a senior director at the organization, said every study she has seen on the effectiveness of therapy is based on appointments occurring at least once a 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 said.

Shelley Rouillard, director of the California Department of Managed Health Care, said her department has not yet looked at whether patients are able to access follow-up appointments and will have more information on how they are faring after a future survey. Still, she said, Kaiser has made improvements since 2017 and so far has met the benchmarks set up in the settlement agreement. She would not share specifics, saying the details are not public.

"That doesn't mean patients aren't having trouble getting services," Rouillard said. "That's happening throughout the health care system."

Access to affordable outpatient therapy indeed remains a national problem. A recent report from Milliman, a health care consulting company, found Americans were dramatically more likely to resort to out-of-network providers for mental health care than for other conditions because of inadequate provider networks.

But given Kaiser's market dominance in California and its reputation as a signature model for integrated care, the system's critics say the continued shortfalls in mental health care are both 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 said. "I don't think they would. I think they would want their loved one to get more treatment than we are able to provide."