.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.

Fred Paroutaud had a gift. Music was a language he had been speaking his entire life. He loved the way he could express himself with his long fingers and piano keys. Tall and slim with salt-and-pepper hair, the Richmond resident had even found a way to make a successful living from it: composing scores for television and movies.

Yet despite having no history of mental illness or drug addiction, Paroutaud suffered a psychotic breakdown at age 57. Unsure of what was happening, his wife, Susan Futterman, took him to see his regular doctor at their health provider Kaiser Permanente Medical Center in San Rafael and was referred to the emergency room. ER staffers then promptly sent Paroutaud to a private, Kaiser-contracted psychiatric facility in Vallejo — St. Helena Hospital Center for Behavioral Health. During Paroutaud’s 72-hour stay at the facility, doctors diagnosed him with having bipolar disorder, otherwise known as manic-depressive illness. Yet despite the fact that Paroutaud was still suffering from hallucinations, doctors discharged him.

Kaiser mental health therapists put Paroutaud in an intensive outpatient group therapy program that included four-hour-a-day sessions four days a week. But most of the other patients in the program were recovering from substance abuse, so Paroutaud felt out of place. He requested to see a therapist one-on-one. Instead, doctors prescribed him with medication, which proved ineffective. Soon he stopped taking it.

Futterman didn’t know what to do with him. He was no longer the confident, caring husband she knew. One day, she found him standing alone in the kitchen of their home in the city’s Point Richmond district, staring at the floor, his eyes unfocused. He was getting worse.

Paroutaud’s unresponsiveness worried Futterman more than his psychotic outbursts. He had a large group of friends that he suddenly had no interest in. He had been an avid vintage car enthusiast and owned a 1967 Lamborghini that he restored himself. He had even helped create an online forum about vintage Lamborghinis. But he had become consumed by a deep depression and was no longer interested in his hobby.

Futterman called Kaiser and asked to set up an appointment between Paroutaud and his psychiatrist. She said she was told that the psychiatrist was on vacation and that no one was covering his patients while he was away. Kaiser staffers recommended that Paroutaud return to group therapy and continue taking his medication. She said she was told repeatedly that Kaiser doesn’t offer one-on-one therapy.

Desperate, Futterman called Kaiser every day for two weeks begging to have her husband seen by a therapist. On June 28, 2012, exactly two months after Paroutaud’s initial breakdown, Futterman came home to find her husband in their living room hanging from a rope tied around his neck. She cut him down and frantically tried to revive her husband with CPR.

It was too late. Paroutaud’s suicide was a tragic end to his brief-yet-intense battle with mental illness.

Unfortunately, this was not an isolated case. Even though federal and state laws mandate that hospitals provide mental healthcare programs that are on par with their primary healthcare services, a growing chorus of patients, state regulators, and clinicians are raising questions about Kaiser Permanente’s mental health services, saying the healthcare giant delays patients’ access to care in violation of the law.

“No one at Kaiser ever looked at my husband as a human being. They treated him like a medical record number. They never really tried to understand what he was going through. Never,” Futterman said. “They claimed to provide the full spectrum of medical services. Either they do not or they chose not to.”

In June 2013, the California Department of Managed Health Care (DMHC) fined Kaiser $4 million — the second-largest penalty in the agency’s history — for providing inadequate mental healthcare, and issued a cease-and-desist order against the healthcare giant for mental health violations. The large fine and intense criticism of Kaiser also come at a time when the nonprofit is being held up as a national model for healthcare.

Kaiser has stated in written reports that the criticisms leveled by DMHC and the $4 million fine are unwarranted. Kaiser officials also contend that the company is being targeted by a healthcare workers’ union campaign to increase staffing.

However, since the DMHC issued the fine to Kaiser a year ago, the number of critics of Kaiser’s mental healthcare programs has grown. Moreover, the problems promise to intensify with the expansion of the Affordable Care Act. The company is dealing with a flood of new patients who signed up for insurance under Obamacare. In addition, the Affordable Care Act mandates that all insurance plans include mental health coverage, a requirement that will likely increase the number of patients seeking mental health services at Kaiser.

While much attention has been focused in recent months on extended wait times at Veteran’s Affairs hospitals — leading to the recent resignation of VA Secretary Eric Shinseki — far less scrutiny has been given to similar problems involving California’s largest health provider.

Susan Futterman filed a class-action lawsuit against Kaiser in October 2013, along with two other plaintiffs from around the state who claim they were denied and delayed access to mental healthcare. Their lawsuit joins two other class-action lawsuits filed in recent months against Kaiser for denying access to mental health services. A fourth suit, a wrongful termination lawsuit filed by a Kaiser psychologist in Sacramento, claims the doctor was fired for advocating for patients to get access to mental healthcare.

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.”

Last October, after six Kaiser Redwood City mental health patients took their own lives, therapists from the hospital’s Adult Psychiatry Department sent a letter to the hospital’s chief of psychiatry, demanding that the department increase staffing. “As ethical and concerned citizens, we bring these issues to your attention in light of the recent spate of suicides in our clinic” the letter stated. “These tragedies have heightened our longstanding concerns that we do not have adequate resources to safeguard our patients and provide quality care. The workload we have struggled with for years and have been asked to even further increase is unsafe and unsustainable.”

According to the therapists, their concerns were never directly addressed. “Since as long as I’ve worked at Kaiser, it [has been] well documented that you can’t get therapy at Kaiser,” said Clement Papazian, a social worker who has been at Kaiser for 26 years.

Clinicians have reported that they have knowingly made inadequate recommendations, such as recommending patients for group therapy when they knew that individual therapy would be more appropriate: “I want to offer something,” said Jeanine Thomas, a Kaiser social worker. “Otherwise people drop out of treatment. And that’s often what we see.”

In an effort to increase access to services, some Kaiser facilities in recent months have reported implementing “cluster intakes,” in which therapists bring in fifteen patients for a short period of time and meet with the first ten to arrive.

“It wouldn’t be unusual to have someone calling me up wanting to harm themselves, and me not being able to see them,” said Melinda Ginne, a Kaiser psychologist. “It’s heartbreaking.”

Ginne sent many emails to her managers at Kaiser Oakland that went unanswered, including one that read: “As a licensed Psychologist, my responsibility is to deliver appropriate care to my patients. That’s what I’m trained to do. That’s what my license and my ethical obligations require me to do. In my professional judgment, it’s clinically unsound and unethical to force high-acuity patients to wait 4-5 months for an appointment. By ordering me to continue adding more patients into my already overburdened caseload, Kaiser will effectively block me from providing clinically appropriate care to my patients.”

Kaiser clinicians are, in fact, the most vocal critics of Kaiser’s mental health services. The NUHW, which represents 2,500 mental health clinicians in California, has led a campaign to raise awareness of Kaiser’s alleged mental health deficiencies. The union is pushing to increase staffing numbers at Kaiser’s medical centers, contending that understaffing is Kaiser’s underlying problem. In 2011, the union released a report that detailed the inadequate mental health services found by their clinicians. Many suspect the report triggered the state’s investigation and subsequent fine.

The union’s report from November 2011, “Care Delayed, Care Denied,” highlighted many of the deficiencies that the DMHC ultimately found. But it contained a few troubling claims that never made it into the state’s findings. For example, more than 50 percent of the Kaiser mental health clinicians surveyed in the NUHW report stated that “patients were either frequently or very frequently ‘assigned to group therapy even though individual therapy may be more appropriate.'” And more than 75 percent reported that “they are either frequently or very frequently ‘forced to schedule return visits further into the future'” than they believed was appropriate.

The NUHW recently sent a letter in June 2014 to US Attorney General Eric Holder, requesting that the Department of Justice investigate Kaiser’s mental health record in light of the VA hospital discoveries. The Department of Justice has yet to respond.

With 9.3 million members, Kaiser Permanente is the nation’s largest nonprofit HMO and by far California’s largest healthcare provider. It is widely recognized as a model healthcare company because its highly regarded integrated services facilitate nearly every aspect of patient care.

“The organization, which combines a nonprofit insurance plan with its own hospitals and clinics, is the kind of holistic health system that President Obama’s healthcare law encourages, ” a recent New York Times article stated about Kaiser.

President Obama himself was quoted on Time.com in 2009 talking about Kaiser. “It’s actually one of the models of high-quality, cost-efficient care that’s out there right now,” he said, “partly because they maintain such a stable base of patients and they construct a whole-team approach that has proven to be very effective.”

Yet that efficiency may be exactly what is impeding Kaiser from delivering costly, resource-intensive mental healthcare. “Efficiency shouldn’t be at the cost of providing services,” said Latika Malkani, a lawyer representing Susan Futterman and the other plaintiffs in one of the class-action lawsuits.

“It is already rated the best health plan in the state by most measures so I think in the long run Kaiser is probably going to be an incredibly great plan. It’s just the way that Kaiser has implemented the behavioral health side of things. If you look at the plan on paper it looks like they provide an incredible array of services. On the ground, it seems Kaiser isn’t living up to its own contract with its enrollees,” said Peter Schroeder, the immediate past president of the California Coalition for Mental Health and a board member of Mental Health Association in California, both of which are nonprofit groups that advocate for mental health services.

In California, nearly one in six adults has a mental health need, and approximately one in twenty suffers from a serious mental illness that makes it difficult to carry out major life activities, according to the California Healthcare Foundation. Nationally, the rates are even higher. “Because mental illness is still so stigmatized in our society, administrative barriers to care that may seem reasonable for physical health can be insurmountable for people seeking mental health treatment,” Schroeder said.

For patients like Paroutaud, Kaiser’s administrative barriers have life-or-death consequences.

Charles Dion is another victim of Kaiser’s allegedly flawed mental healthcare system. Dion is a plaintiff in one of the class-action lawsuits against the nonprofit, claiming that he was denied treatment at Kaiser Oakland for his severe obsessive-compulsive disorder (OCD). Dion said he was denied individual therapy and was referred to the Anxiety Treatment Center of Sacramento, a non-Kaiser clinic nearly one hundred miles from his Oakland home.

Kathleen (whom the Express has agreed to not fully identify) ran into similar problems when seeking treatment for her sixteen-year-old daughter’s depression. Though Kaiser initially prescribed “talk therapy” for her daughter, Kathleen, who lives with her daughter in Martinez, found that sometimes it would take five weeks to get an individual therapy appointment. “While medication and group therapy have been made available and [my daughter] has willingly participated in both, talk therapy has been almost nonexistent,” Kathleen wrote in a letter to Kaiser’s Department of Mental Health in Walnut Creek. She was caught off-guard because her family had had such positive experiences with Kaiser’s primary healthcare over the years. “We’ve had such good care and we really embrace Kaiser’s model,” said Kathleen. “It was jarring to have this experience with mental health services.”

Both Dion’s and Kathleen’s stories fit the narrative Kaiser clinicians and therapists describe: Kaiser staffers have no way to keep up with the numbers of patients requiring services. In fact, there are currently no limits on caseload size for non-physicians in Kaiser’s behavioral health departments.

Kaiser officials, for their part, strongly defend the quality of mental health services they provide. “We are really leading the country in terms of figuring out how to provide the best mental care we can to the largest number of patients,” said Turner. Turner also said that since 2012, Kaiser has increased staffing in Northern California, and that a majority of the new staffers have been therapists. However, I was unable to verify this assertion.

He and other officials view the recent focus on mental healthcare quality partly as an effort by the NUHW to settle an ongoing labor dispute. After a one-day strike in April by Kaiser mental health services staff in Oakland, Don Mordecai, director of Mental Health and Chemical Dependency Services for Kaiser Permanente Northern California responded by stating, “We strongly disagree with the union’s claims that this is about the quality of mental health care at Kaiser Permanente.” In a prepared statement, he continued, “Over the past two years, we have increased staffing in our Oakland Psychiatry department nearly 20 percent. The union is objecting to changes which have already been implemented and which benefit our members. In addition, we are bargaining to establish a dedicated after-hours, on-call team to handle psychiatric emergencies at our Oakland and Richmond medical centers.”

According to healthcare regulation experts, these issues are not completely unique to Kaiser. Both state and federal laws require that healthcare plans provide mental health services to the same standard as primary healthcare. But just how these health parity laws should be enforced is a matter of concern across the country. Currently, states have the primary authority to enforce mental health parity laws, but if the federal government determines that the state is not enforcing the law, then it can step in and enforce it. Federal parity laws, recently amended with the Affordable Care Act, are decidedly stronger than state laws.

In California, laws such as California’s Mental Health Parity Act, the Knox-Keene Health Care Services Act, and Timely Access laws provide protection for mental health patients. But critics claim the DMHC has not been aggressive in its enforcement of these laws, which makes the fine against Kaiser particularly noteworthy.

In May, under pressure from the state legislature, the DMHC started holding monthly stakeholder meetings with the mental health community. According to Peter Schroeder of the California Coalition for Mental Health, the meetings are part of an effort to improve an agency he described as “excruciatingly slow” in completing enforcement actions. Although he admits that the DMHC is improving, Schroeder has been disappointed with its regulation of mental healthcare of all providers in the state — a problem he believes extends far beyond Kaiser.

While critical of Kaiser’s mental health services, Schroeder sees a lack of regulation by the DMHC as the underlying issue. “Their job is not to make health plans more efficient,” he said. “Their job is to help consumers. And they seem to interpret that in a way that is perplexing to many of us.”

Randall Hagar, director of government relations of the California Psychiatric Association, likes the new direction the DMHC is heading, particularly the stakeholder meetings. “The department has shown that they get a very complex law, which is very hope-inspiring,” he said.

After the Mental Health Compliance Act failed to pass the state legislature last year, Hagar has helped lobby for a bill currently moving through the California legislature. Authored by state Senator Jim Beall and recently amended in the state assembly, SB 628 includes more funding to the DMHC to conduct medical surveys for the enforcement of mental health parity laws. Advocates hope the bill will move rapidly through the legislative process to meet an upcoming August 31 deadline.

An increase in funding could potentially give the DMHC the resources to more broadly enforce parity laws throughout the state and improve transparency within the agency. “When we look back, I’m really hoping that we’ll be able to say that we helped a lot of consumers get access to services in a timely way and even better quality services than they would have without these efforts,” Hagar said.

The Affordable Care Act threatens to intensify the challenges of providing mental healthcare. According to Kaiser internal emails, the HMO is expected to gain 52,000 Medi-Cal patients in the Northern California region alone this year. Overall in California, Kaiser has seen a 1 percent growth in membership, gaining about 86,000 new members through Covered California, according to Turner. “Wait times are only getting worse with the advent of Kaiser’s participation in Covered California,” said Andy Weiskoff, a former Kaiser social worker in Santa Rosa who recently resigned in protest of the mental health services and has been documenting his experiences on a blog.

Following the guidelines of the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act of 2008, the Affordable Care Act now mandates that coverage for mental health and substance abuse services cannot be any more restrictive than for medical services. These protections will expand mental health and substance abuse benefits and parity protections to more than 62 million Americans. According to the US Department of Health and Human Services, that growth represents the largest expansion of behavioral health coverage in a generation.

Although technically a nonprofit, Kaiser is growing at a rate unprecedented in the healthcare industry. In June, Kaiser announced first-quarter net revenues of $1.1 billion, up nearly 44 percent from a year ago. In July, Kaiser opened a new 12-story hospital in a $1.3 billion facility in Oakland that also includes a 100-office medical building and 1,200-space parking structure.

The questions raised about how Kaiser treats patients with mental health concerns are particularly troubling considering this rapid growth.

“I thought Kaiser would be cost effective but it turned out to be a fatal mistake,” said Susan Futterman. “I want Kaiser to change its policy — Kaiser does not provide appropriate mental healthcare to its members.”

Correction: The original version of this story misspelled Latika Malkani’s first name.


Please enter your comment!
Please enter your name here

East Bay Express E-edition East Bay Express E-edition