Mental health care at Kaiser in dispute

A former Kaiser Permanente psychotherapist is raising troubling questions about the way Sonoma County's largest health care provider treats patients with mental illness.

Andy Weisskoff, who worked as a psychotherapist at Kaiser for nearly eight years, accuses the HMO of giving short shrift to one-on-one therapy and under-staffing the ranks of therapists. The practice, he claims, creates long waits between individual therapy sessions, leading to a deterioration in his patients' mental health.

Weisskoff gave 90 days' notice to Kaiser in February and began blogging, citing his frustration with what he calls an understaffed system that allows little time for crucial therapy.

Kaiser maintains this is at essence a union dispute and says Weisskoff, a union shop steward, refused to cooperate when the HMO sought to investigate his allegations. In early May, three weeks before his resignation was effective, Kaiser asked him to leave.

"I left the job because I was unable to provide the kind of care that I was trained for and that clients needed in order to get better," Weisskoff said. "I blogged because the vast majority of therapists and clients are struggling in this dysfunctional system, and I was hoping that it would help address deficiencies in the system."

His outspoken criticism has resonated with some Kaiser mental health patients and their families.

Sonoma County Supervisor Shirlee Zane, whose husband was treated by Weisskoff before his 2011 suicide, is among those who contend Kaiser does not give mental health issues -- such as major depression, post-traumatic stress disorder or personality disorder -- the same high priority it gives to cancer, heart disease and diabetes.

"Kaiser is important. They are a contained health care system -- they should do better," Zane said.

In February, Weisskoff wrote the first of more than 60 posts on a scathing blog that provides an insider's look at the operations of Kaiser's psychiatry department in Santa Rosa -- and casts a light on a simmering dispute between Kaiser and the union that represents its therapists.

On Thursday, the National Union of Healthcare Workers called on the U.S. Department of Justice to launch a criminal investigation into allegations that Kaiser Permanente delayed care and falsified appointment records for thousands of mental health patients.

Kaiser dismissed the action as a union ploy. It strongly rejects the accusation that it does not provide appropriate levels of mental health care to its members, or as some claim -- including Zane -- that it is "rationing" mental health services to control costs.

"Absolutely not. ... We do not ration care," said Dr. Mason Turner, director of patient operations for regional mental health services at The Permanente Medical Group, the plan's regional medical group for Northern California in Oakland.

Kaiser says Weisskoff's allegations, which it is investigating, must be viewed in the context of protracted labor negotiations between the nonprofit HMO and the National Union of Health Care Workers. Weisskoff was a shop steward for the NUHW, which represents about 1,600 of Kaiser's 67,000 nonphysician employees in Northern California. The union, Kaiser officials said, is trying to apply pressure by disparaging the HMO and undermining its reputation.

Kaiser defended its Northern California mental health care, which it said is one of the highest rated in the state, according to the 2014 California Office of the Patient Advocate report card.

Turner said Kaiser continually assesses and evaluates its services and looks for ways to improve, taking "very seriously" feedback from members, patients and the community. In terms of staffing, Kaiser has embarked on an aggressive campaign to boost its service capacity, he said.

"We constantly look at staffing," he said. "We have increased staffing throughout the region."

Stunned by departure

Chelsie Martinez was stunned when she discovered why her psychotherapist at Kaiser Permanente had quit.

The Ukiah woman and her therapist, Weisskoff, had delved deep into her past using eye movement desensitization and reprocessing therapy, or EMDR. It is Weisskoff's specialty. With his guidance, they painfully revisited years of sexual abuse and trauma, focusing on the flashbacks that were consuming her.

The EMDR treatment she was getting was intense and felt like a "roller-coaster" ride because of the long waits between sessions.

"It's hard, it's really hard, because you have just relived a moment that is basically defining you today. It's hard because nobody wants to remember things that are bad," she said.

"The longer a wait I have, the more likely I am to not go, because I have the opportunity to convince myself not to," Martinez said. "With the long intervals between appointments, it makes it easier to just feel like you don't want to go back up that hill."

The sessions rarely came more than once a month, but they were helping, she said.

Then he was gone.

Weisskoff had told her he had given his notice and intended to quit to start his own practice, but she didn't think their sessions would end so abruptly. Martinez said she felt angry and alone and even began thinking of suicide.

A Google search led her to a blog that Weisskoff had been writing for several weeks but never discussed with Martinez.

"I read the blog from beginning to end, all in one sitting. I don't know if I even slept that night," Martinez said.

For nearly three months, Weisskoff -- in his blog titled "90 Days to Change" -- wrote about some of the inner workings of Kaiser's adult mental health program in Santa Rosa.

Weisskoff's blog, Martinez said, jolted her from her long-held belief in Kaiser's values and the quality of care she was receiving at the HMO.

"It's disheartening to me to believe that they didn't really have my best interest," Martinez said. "It made me sad. I felt like I was a part of something great, a part of something that people don't have, a part of a family of people that care about your mental health and well-being -- it kind of made that not so real anymore."

Martinez has resumed therapy sessions with Weisskoff at his private practice in Sebastopol.

Weisskoff's allegations come less than a year after the California Department of Managed Health Care, or DMHC, levied a $4 million fine against Kaiser for what it termed serious deficiencies in providing timely access to mental health services. It was the second-largest fine in the history of the regulatory agency, which was created in 2000.

Following a routine survey conducted in the first half of 2012, state regulators found that Kaiser was not accurately tracking patients' access to the HMO's therapists. The agency also said Kaiser could not ensure that patients were offered timely initial appointments with therapists for non-urgent matters, in violation of state regulations.

Incorrect materials

In addition, the DMHC found Kaiser was distributing educational materials that described limitations in mental health benefits. Regulators said the information may have discouraged members from seeking services Kaiser must cover under the state's Mental Health Parity Law, which requires health plans to provide the same level of benefits for mental illness as they do for physical illness.

Similar issues were highlighted in a 2011 report by the National Union of Healthcare Workers called "Care Delayed, Care Denied." The union report claims, among other things, the HMO severely understaffed its mental health services and failed to provide timely access to individual therapy as required by state law.

Kaiser argues that it has worked aggressively to improve the deficiencies identified in the 2012 survey. It has taken steps to reduce wait times for initial, non-urgent therapy appointments; hired new therapists; updated inaccurate educational materials; and improved its ability to monitor patients' access to mental health care.

In light of these steps, Kaiser believes the proposed $4 million penalty is excessive and is challenging the fine. A hearing is scheduled Sept. 8 before an administrative law judge in Oakland.

Regulators "did not identify problems with the quality of mental health care provided to our members or with the ability of our members to obtain urgent or emergency mental health care," said Dr. Don Mordecai, director of mental health and chemical dependency services for Kaiser Permanente Northern California, in an extensive written response to Weisskoff's allegations and blog.

Wait times disputed

Under the state code of regulations that deals with managed health care, health plans must ensure that plan members are able to make "non-urgent appointments" with nonphysician mental health care providers such as therapists "within 10 business days of the request for appointment."

Kaiser says the vast majority of such appointments are now booked within that time frame.

But Weisskoff, who worked for Kaiser's adult psychiatry team in Santa Rosa, said he has firsthand knowledge of how Kaiser is meeting that goal.

Weisskoff said that in an attempt to reduce the initial appointment wait times, Kaiser had its therapists juggle their schedules and spend more hours on intake appointments by reducing the number of hours on "returns" or follow-up care, the meat of the individual therapy process.

Before the DMHC fine, the ratio of hours he spent on returns to intakes was 3 to 1, Weisskoff said. During his final months working at Kaiser, it was 2.5 to 1, he said.

"Over time, our return slots have been fewer and fewer," he said. "That's because more of the resources have gone to initial time slots because it's incredibly important for local departments to meet this initial access regulation."

Weisskoff said his wait times for follow-up care went from three to four weeks a few years ago to four to five weeks a few months ago. Weisskoff contends that wait times have gotten worse since Kaiser began participating in the state's Covered California health insurance marketplace, which added more insured patients to Kaiser's rolls, leaving therapists like him with even less time to provide care.

Union officials said wait times for individual follow-up sessions can be anywhere from four to seven weeks, citing interviews with union therapists.

Kaiser officials strongly rejected claims that wait times for follow-up care were as high as seven weeks because of understaffing, or that Kaiser mental health staff are being inundated by patients newly covered by the Affordable Care Act.

Kaiser said it has increased its therapist staff by 14 percent in Northern California and the actual number of new members added through Covered California amounted to less than 1 percent of its membership.

Mordecai said every patient's situation is unique and they are evaluated and treated individually.

"There is no such thing as an 'average' time for additional visits, or an average range of additional visits," he said.

He said appropriate treatment usually involves a "multitude of formats" which in some cases provide more "intensive and higher levels of care than individual visits with a therapist."

Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, said the question of appropriate wait times for therapy sessions is a "relative" one.

There is no national standard for management of mental health benefits, said Mander-

scheid, co-chairman of the Coalition for Whole Health in Washington, D.C., which monitors implementation of the Affordable Care Act. The law includes mental health parity, which ensures that health plans cover mental health service at the same level as physical health services.

Weisskoff, who joined the Adult Psychiatry Department at Kaiser in 2006 and became a union shop steward at the beginning of 2014, said there never were enough therapists during his time at Kaiser to meet the need for those who require or desire individual therapy.

"Kaiser does not provide the individual psychotherapy time that the clients need in order to get better," Weisskoff said.

'Narrow view'

Turner said Weisskoff's complaints reflect a "narrow view" that individual therapy is the best kind of mental health service. He said Kaiser offers a full spectrum of behavioral health services aside from individual therapy, including intensive outpatient programs, group therapy, short-term residential programs, medication management visits and inpatient hospitalization.

"There is no evidence that individual therapy is better than group therapy," Turner said. "What you're seeing is a really narrow view that individual therapy is the gold standard and that is simply not true. It's not the gold standard."

Also, Mordecai said, Weisskoff does not acknowledge that most of Kaiser's mental health patients receive individual therapy. For example, in 2013 more than 70 percent of Kaiser's patients receiving mental health services, excluding chemical dependency patients, had only individual visits.

Weisskoff said people who get discouraged and stop care after one visit could be affecting Kaiser's numbers.

He argues that it is not a question of what type of service is better, but rather that timely individual therapy is a crucial component of therapy services. He said the consequences of people not receiving timely individual therapy can be dire.

"It's a small number of people who will commit suicide because they're not receiving that individual time," he said. "The vast majority will continue to suffer with their mental health symptoms."

Family frustrated

For Corlene Van Sluizer, 70, of Santa Rosa, Weisskoff's blog echoed the frustration she felt trying to get one-on-one therapy for her sister Karen Townsend.

Van Sluizer said Kaiser has sought to steer her sister into group therapy and restricted access to individual therapy, which had greatly helped her sister in the past. Townsend's psychiatrist responded to Van Sluizer's concerns by insisting the support Townsend needs is best provided by a group setting.

Van Sluizer said the Kaiser psychiatrist told her they could seek a therapist outside Kaiser, suggesting the Lomi Clinic in Santa Rosa or the Family Services Agency, which offer affordable therapy sessions on a sliding-fee scale.

In April, Townsend spent four days in Kaiser's emergency department before medical staff there could find an inpatient psychiatric facility that would take her, Van Sluizer said.

Townsend, who suffers from major depression, was taken to the Kaiser emergency room after she told her psychiatrist she was feeling suicidal and had a plan to carry it out -- overdosing on her medications.

Van Sluizer, a retired art therapist, recently protested outside Kaiser's Bicentennial Way medical campus with a large brown papier-mache mask adorned with Townsend's empty medication bottles and white cotton balls stuffed in its mouth.

A sign beneath the mask read, "Kaiser Mental Health,

No Psych Facility; Pills + Little Therapy." The sign also listed Weisskoff's blog,

90daystochange.com.

Van Sluizer said she was first alerted to Weisskoff's blog by a Kaiser staff member when Townsend was in Kaiser's emergency department. She said the blog confirmed her own experience with trying to get one-on-one individual care for her sister.

"There's no ongoing, one-on-one therapy," she said. "They'll give a little bit here and a little bit there, but there's no ongoing therapy."

While Van Sluizer protested outside Kaiser's main Santa Rosa campus, two Kaiser representatives approached her in an attempt to address her concerns. She met with Guy Chicoine, medical group administrator, and was told that her concerns about her sister would be looked into.

Van Sluizer said the four days she spent in the emergency department with her sister illustrated to her the need for Kaiser to improve its mental health offerings, including offering more individual therapy. She asked why Kaiser did not have an inpatient psychiatric facility for people like her sister.

Kaiser spokesman Carl Campbell said in a statement that Kaiser contracts with inpatient psychiatric facilities in each of its service areas "to provide the best possible access to this specialized care for our members."

"It is important to keep in mind that there is a well-known shortage of inpatient psychiatric beds in California," Campbell said. "Kaiser Permanente is working with community and government groups and others on strategies to improve this situation."

You can reach Staff Writer Martin Espinoza at 521-5213 or martin.espinoza@pressdemocrat.com.