When the nation’s leading association of professional psychologists singled out California health industry giant Kaiser Permanente last year as the worst mental health care provider it has encountered, the group was expressing what had become common knowledge to many mental health therapists and patients alike: Too many of Kaiser’s members cannot get in the door for behavioral health treatment.
The American Psychological Association’s (APA’s) blistering and previously undisclosed assessment said that, in two decades of reviewing actions by mental health care providers, “We have never seen such an egregious case of delayed access” to care.
Kaiser Permanente casts an enormous shadow across California’s medical and political landscape. A health care behemoth operating in eight states and Washington, D.C., it both insures and provides medical services for more than 9 million people in this state alone—nearly one in every four Californians.
As both California’s largest health insurer and its largest operator of hospitals, Kaiser is of pivotal importance in determining the success of long-standing national and state-level mandates intended to make mental health care as readily available to patients as is care for their physical ailments. New policies adopted by Kaiser have a way of quickly migrating to other medical systems, whereas programs that Kaiser rejects may not have an easy time gaining acceptance elsewhere.
Ben Goldstone, a licensed marriage and family therapist (LMFT) at Kaiser in Berkeley, compared Kaiser’s influence over California’s health care industry to that of Facebook’s authority in the tech sphere and Amazon’s hold on e-commerce. “They’ve got such clout in the market, they could actually change things,” he said.
According to the APA and other observers, Kaiser continues to ignore calls to match the level of its treatment of mental illnesses and substance use disorders with that of its care for physical health conditions—an equation known as mental health parity.
Beth Capell, a legislative advocate for Health Access California, a health care consumer advocacy coalition, says that the obstacles muddying the path to equal treatment of mental and physical health conditions are well established within the health care industry.
“Equally well known,” she said, “is the lack of mental health parity—the lack of respecting the reality that mental health needs are just as important as physical health needs.”
Importantly, general standards for mental health outpatient treatment call for at least once-weekly therapy sessions in order for significant progress to be made, but Kaiser’s critics maintain the company has failed at this and, instead, has attempted an end run by creating a network of call-in centers for its mental health clients.
According to Kaiser patients, therapists, state reports, and the APA, the waiting period between appointments at Kaiser can range anywhere from four to six weeks. At some of the most understaffed Kaiser clinics in the state, that waiting period between sessions can be two to four months—leaving some patients frustrated with their struggle to access care.
“Making people with mental illness, especially depression, jump through a bunch of bureaucratic hoops to get care is like making somebody with a broken leg jump through physical hoops to get care,” said Greta Christina, a writer and Kaiser mental health patient of about 20 years.
A poll of more than 2,000 Kaiser therapists taken late last year by their labor union, the National Union of Healthcare Workers (NUHW), found 80% complaining that understaffing prevented them from providing patients with appropriate and timely care. This difficulty, many of them said, applied to patients with both severe and moderate mental illness and substance use disorders. (Disclosure: The NUHW is a financial supporter of Capital & Main.)
The union’s poll also suggested that the coronavirus pandemic has only worsened the access problem at Kaiser. The NUHW informed state regulators early this year that one-third of the therapists surveyed reported that since the start of the COVID-19 crisis, they had seen an increase in negative outcomes—”in particular, suicides or overdoses.”
In the APA’s bleak assessment, sent to state regulators in January 2020, the association noted a glaring difference between Kaiser patients’ experiences in its medical and mental health divisions.
“Kaiser’s access to medical care seems to be very adequate,” the APA wrote, “leaving the company with a dramatic disparity between good access to medical care and terrible access to mental health care.”
The APA claimed Kaiser could solve this problem if it wanted to by simply hiring more therapists, but that Kaiser as an institution appeared to be in denial that it had a serious problem.
“We believe that Kaiser could hire more therapists readily if it admitted that this problem exists and chose to commit some of its ample resources to fixing it,” the APA said in its letter. “The only explanation that Kaiser offered us was to cite a State of California study indicating an 11% shortage of psychologists and other (non-psychiatrist) mental health providers, but the study actually referred to a projected shortage a decade from now.”
Kaiser’s resources, indeed, appear to be ample enough. The credit rating agency Fitch Ratings said last year that Kaiser-issued bonds were a good buy for investors because of “Kaiser’s long track record of extremely consistent profitability.” In 2020, Kaiser reported a total operating revenue of nearly $89 billion—about $60 billion of which was generated in California, according to Fitch’s most recent report.
In a response to questions for this story, Kaiser Permanente released a statement that read, in part:
The American health care system historically has been under-resourced for mental health. The COVID-19 pandemic has only exacerbated this situation. Providers across the country—including Kaiser Permanente—are working hard to address the growing demand and emerging mental health crisis.
Kaiser Permanente’s work to expand options to meet the ever-increasing demand for mental health services began ahead of the pandemic. We’ve placed specific emphasis on expanding the number of therapists in California, and despite the national and state shortage of trained mental health professionals, we have hired nearly 600 therapists in California between 2016 and the end of 2020—and we continue to hire more.
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For at least two decades, both the federal government and the California state legislature have mandated that insurers provide access to mental health and substance use disorder benefits on par with its medical and surgical benefits—but health insurers, including Kaiser, have resisted.
“Their position was, for many years, that mental health was not as important as physical health and they didn’t treat it,” Capell said. “Now they treat it like a step-child.”
Capell noted that Kaiser resisted providing adequate access to mental health care “even when they had data from within Kaiser that managing mental health and substance use treatment improved physical health.”
Kaiser’s inability to properly comply with mental health parity laws first came to light in 2013 when California’s Department of Managed Health Care (DMHC) levied a $4 million fine against the insurer—the second-largest penalty ever imposed by the DMHC.
In a routine survey of Kaiser’s operations, the DMHC uncovered these severe deficiencies in its behavioral health division:
- Kaiser made patients wait excessive amounts of time for initial and follow-up access to therapy.
- Patients were presented with inaccurate information about the availability of mental health services.
- Kaiser’s data tracking system did not accurately calculate, measure, or monitor wait times of scheduled appointments.
In addition to the fine, the DMHC slapped Kaiser with a cease and desist order demanding that it immediately stop engaging in the unlawful conduct revealed during the department’s survey.
Initially, Kaiser contested the fine, calling it “unwarranted and excessive,” but later agreed to pay it, possibly wishing to avoid a potentially embarrassing public hearing.
Kaiser also admitted that its own internal investigation matched the findings of the DMHC and pledged to remedy the flaws brought to light—the chief concern being that patients were unable to access non-urgent initial therapy appointments within the legal time frame of 10 business days.
But the matter didn’t end there. As DMHC continued to monitor Kaiser’s adherence to parity regulations over the following four years, the timely access issues remained.
By 2017, after millions of dollars in fines and over 100 enforcement actions levied against it by the agency, Kaiser had done little to fix the problem. The parties then entered into a settlement agreement to address Kaiser’s persistent inability to offer mental health services at parity with medical services.
The settlement set out goals for Kaiser to meet to ensure shorter wait times for patients, with help from a third-party consultant to help oversee the behavioral health care system.
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In 2018, shortly after the settlement, Kaiser established a Connect2Care (C2C) call center to address regulatory concerns regarding initial appointment access times in the Northern California region. There are currently two centers servicing the state, located in Livermore and San Leandro, that house licensed behavioral health providers who are responsible for intaking, assessing, and coordinating follow-up care for patients during 30- to 60-minute phone calls.
Some therapists interviewed for this story allege the C2C centers were established for Kaiser mostly to placate regulators by obtaining and reporting improved data for initial appointment access—the main deficiency noted by the DMHC in three consecutive reports.
Although such over-the-phone intakes are conducted by a licensed behavioral health care provider, the APA described them as “short-cut assessments that are inconsistent with professionally recognized standards of care for mental health evaluations.”
Dr. Michael Torres, a Kaiser child and adolescent psychologist in Alameda, said that for his young patients, the C2C centers are particularly problematic.
He alleges that initial intakes intended to assess children and teen patients are often conducted without them present. Rather, the parent is interviewed about the child’s symptoms, and the third-party assessment is billed as an initial appointment for the child, according to Torres.
Torres explained that Kaiser can then report higher access to initial appointments—even though these first phone screenings do not meet recognized practice standards, and do not include the child or adolescent.
“They’re using that initial call center phone screening in place of an actual first-time clinic appointment for the child or adolescent,” Torres said. “That’s how Kaiser manipulates the initial access numbers.”
Alan Nessman, senior special counsel for the APA’s Office of Legal and State Advocacy, likened the alleged data manipulation at Kaiser to the educational concept of teaching to the test.
“If you can manipulate your data in a way that matches the regulatory requirements, at least on paper,” Nessman said, “then that becomes a reason why the DMHC hasn’t found a violation.”
Ilana Marcucci-Morris, a licensed clinical social worker (LCSW) and intake assessment coordinator at one of Kaiser’s C2C centers, explained that call center clinicians attempt to assess a patient’s needs, but do not offer therapy.
“We’re conducting a structured interview to determine what type of treatment is needed,” Marcucci-Morris said. “It’s not a therapy session.”
Once patients complete the initial intake assessment with a C2C representative, they are processed into an utterly overwhelmed system in which therapy appointments may not be available for four to six weeks.
Kaiser has contracted external providers and hired more therapists to try to offset the demand for therapy—but even so, Kaiser’s in-house therapists say the efforts have fallen short and they remain inundated by the amount of need.
Paul Wager, an LMFT at Kaiser in Anaheim, said that although the external network helps relieve some pressure, it isn’t nearly enough to allow him to see his patients on a regular basis.
“We’re only allowed to refer people to the outside network who are relatively stable, and those tend to be the people who don’t need the weekly therapy as much as people that are in a more acute condition or have chronic conditions,” Wager said.
Thus, some patients with both severe and moderate symptoms of mental illness are left without timely access to consistent therapy—and therapists are left frustrated by their inability to help these clients.
“It’s tough on the patient, but it’s very tough on the clinicians, too,” said Wager. “We want to help folks heal, and when you’re not able to get folks back in a timely manner, that whole process gets super elongated.”
Capell said that too often, Kaiser patients are left with no option but to search for care out-of-network.
“The reason they have health insurance is to provide coverage for these major conditions and ongoing chronic conditions,” Capell said. “That’s the sort of thing that can ruin a family pretty easily.”
Malynda Eastman, an LCSW employed at Kaiser for 15 years, recently opted for early retirement. Eastman said that after years of bearing witness to her patients’ suffering without the care they need—and as often as they need it—she can no longer “morally do what we’re doing.”
Eastman explained that the need for treatment shot up once the pandemic hit. She alleged she had to make patients she feared might be suicidal, as well as patients who were grieving the death of a family member to COVID-19, wait weeks on end for therapy. Despite the patients’ urgent need for treatment, Kaiser’s system made it impossible for Eastman to book them sooner than four to six weeks out, she said.
“I feel like I’m hurting them more than helping when I have to send them away,” Eastman said.
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Since the NUHW began representing Kaiser therapists in 2009, the union has mounted a pressure campaign against Kaiser Permanente to fix its access and parity problems. Its petitions triggered the 2013 DMHC investigation and subsequent $4 million penalty.
But now, both the union and the APA fear that DMHC’s tools to enforce parity may be ineffective against Kaiser.
“We’re hoping the DMHC would be the solution,” the APA’s Nessman said. “I don’t see us stopping if the DMHC gives them a stamp of approval and we’re still seeing the same level of alleged problems.”
The DMHC, in its most recent report, says that Kaiser has “undertaken appropriate efforts” to meet the terms of its settlement—but according to the NUHW, the department has been unwilling to share with the union documents supporting that assessment.
“Their loyalty should be to the public, to the taxpayers, to the consumers,” Fred Seavey, the union’s director of research, said of the DMHC. “They wrote an agreement that shields these records from the public view. It just doesn’t seem fair or appropriate.”
After a 2020 DMHC meeting in which the union presented evidence—including opinions from the APA and California Psychological Association—that the access problem is ongoing and serious, the DMHC has not responded further.
A DMHC spokesperson told Capital & Main that the department “is committed to using its full authority to ensure enrollees have access to behavioral health care when they need it, and to holding health plans accountable to the timely access standards and mental health parity,” and that the agency continues to investigate issues raised by the APA and the NUHW.
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Patients and clinicians alike are still waiting for Kaiser’s purported progress to trickle down to their day-to-day experiences.
Concern regarding access to timely mental health services isn’t specific to Kaiser patients and clinicians—it’s echoed by the experiences of the California public in general.
A 2020 California Health Care Foundation poll found that the chief health concern of Californians was “making sure people with mental health problems can get the treatment they need.”
Additionally, the poll revealed that “nearly 9 in 10 also favored enforcing rules requiring health insurance companies to provide mental health care at the same level as physical health care—at parity.”
On a national level, regulators have been attempting to enforce mental health parity since 1996—when the federal government implemented the first iteration of the Mental Health Parity Act. Shortly after, California followed suit with its own state parity laws.
The past 25 years have seen countless amendments to both federal and state parity laws—but they are still limited in scope.
The largest expansion to the statutes by far came after a 2019 ruling against United Behavioral Health (UBH). A class action lawsuit filed in Northern California on behalf of 50,000 patients who had been denied mental health treatment by UBH revealed that the insurer had imposed administrative obstacles that made it difficult for patients to access mental health treatment.
In response, California lawmakers introduced and enacted Senate Bill 855, which now requires insurers to provide medically necessary care for the full range of mental health and substance use disorders as recognized in clinical manuals, and requires that care be consistent with professionally recognized standards of care.
This year, another measure—Senate Bill 221—is under consideration in California. If passed, the law would codify the DMHC’s regulations on timely access care and require that health insurers provide non-urgent follow-up appointments with a mental health provider within 10 business days of the previous appointment.
Beth Capell noted that legislative and policy changes are not the only obstacles to achieving mental health parity.
“It’s overcoming the ancient prejudice against mental health treatment,” she said. “The prejudice that much of the physical health world has, and that persists in various forms to this day. Mental health is treated as a second class. It’s a long fight to get equality.”
For patients like the writer Greta Christina, who suffers from depression and anxiety, the promise of parity may be too little too late.
Christina said she had a therapist outside of Kaiser whom she’d seen on a weekly basis for about four years—until she was feeling stable enough to end treatment. But in 2016, symptoms of her depression had resurged and she wanted to start therapy again.
By then, her longtime therapist had joined the Kaiser system—and rather than go through the process of finding a new therapist and paying for treatment out of pocket, Christina opted to stick with her now-Kaiser therapist.
At first, the appointments ranged from every two to three weeks, but as the years at Kaiser lengthened, so too did the time between her therapy sessions.
“And now, I’m lucky if it’s every four, every five weeks, every six weeks,” Christina said. “And that’s just not enough.”
Christina claimed she had made every effort to get in touch with Kaiser’s member services and resolve the problem—but, she said, her phone calls went unreturned and emails unanswered. Eventually, the obstacles were too great for her to overcome.
“The last four years, and the last year, have been constant crisis,” Christina explained. “I can feel myself breaking. I’ve been feeling myself just taking damage that I don’t know will heal.”
Christina has considered giving up on Kaiser completely and searching for a new out-of-network therapist. But doing so is easier said than done, and now she feels caught between two bad choices: “It’s work with my therapist who knows me, but who I can’t see often enough,” Christina explained. “Or break somebody else in and go through all the upheaval and instability of that, just so I can see somebody as often as clinically necessary.
“I really resent that that’s the choice that I’m faced with,” she said.
Kristy Hutchings is an investigative reporter in Los Angeles. You can see more of her work here.